Utilization Review Committee: Form and Function

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Utilization Review Committee Form and Function

• Dana Pepper, RN, MBA, MPA
• The Joffit Group, Inc.
• 2009

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Agenda

• Utilization Management/Review Process for CAHs
• Definitions, Regulations and Requirements
• Utilization Management/Review Methods
• Utilization Management/Review Committee Structure
  and Functions
• Evaluation of the Utilization Review/Management
  Process
• Comments on RAC Readiness

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Utilization Review or Utilization Management?
(you have to do both)

• Health care professionals tend to use the terms
  as interchangeable
• Utilization management describes a proactive and
  concurrent process that seeks to ensure
  appropriate and efficient use of health care
  resources
• Utilization review by definition is more backward
  looking considering whether health care was
  appropriately applied after it was administered

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Regulations and Requirements for the Utilization
Management/Utilization Review (UM/UR) Process

• The CAH carries out or arranges for a periodic
  evaluation of its total program (at least
  annually) that includes a review of
• The utilization of CAH services, including at
  least the number of patients served and the
  volume of services C332
• The CAH determines whether utilization of
  services was appropriate, that established
  polices were followed, and any changes needed
  C335

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Regulations and Requirements for the Utilization
Management/Utilization Review (UR/UM) Process

• CAH quality requirements link with utilization
  management/review requirements
• The CAH has an effective quality assurance
  program to evaluate the quality and
  appropriateness of the diagnosis and treatment
  furnished in the CAH and of the treatment
  outcomes C336

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Regulations and Requirements for the Utilization
Management/Utilization Review (UM/UR) Process

• The hospital must have in effect a utilization
  review (UR) plan that provides for review of
  services furnished by the institution and by
  members of the medical staff to patients entitled
  to benefits under the Medicare and Medicaid
  programs.
• 42CFR482.30(c)(1) Standard Scope and frequency
  of review.The UR plan must provide for review
  for Medicare and Medicaid patients with respect
  to the medical necessity of
• (i) Admissions to the institution
• (ii) The duration of stays and
• (iii) Professional services furnished,
  including drugs and biologicals.

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Utilization Management/Review Plan

• Typical UM/UR plans contain
• Goals and Objectives such as -to support the
  hospital's mission and vision through collection
  and review of data that assures the appropriate
  allocation of hospital resources and how to
  accomplish that list methods, etc
• Committee Structure and Functions

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Utilization Management/Review Plan

• Description of the role of each committee member
• Description of data collection
• Description of feedback loop to Quality
  Management Department, to Administration, to the
  Board, etc
• Description of the Plan approval process and
  frequency of approval

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Utilization Management/Review Methods

• Data driven
• Evidence based
• Use available resources ex. Interqual, Milliman
• Use protocols when possible
• Focus on point of entry
• ED
• Surgery
• Outpatient scheduling
• Physician office

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Utilization Management/Review Committee Structure
and Functions

• Multidisciplinary is most effective
• Physicians
• Physician Extenders NPs, PAs
• Quality Management leader
• Administrators
• Business Office representatives
• Case managers/discharge planners/admission
  coordinators
• Nursing leadership especially those that
  represent the ED
• Therapies - PT, OT, ST
• Coders/HIM

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Utilization Management/Review Committee Structure
and Functions

• Recommended structure and functions include
• The UM/UR Plan is the guide to all activities
  including the Committee functions and structure
• Meet at least quarterly
• Designate a process for review
• Admission reviews obs, inpatient, outpatient
• Continued stay reviews inpatients, swing bed
  patients, rehab patients
• Focused reviews review of known or suspected
  problem areas or cases

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Utilization Management/Review Committee Structure
and Functions

• Recommended structure/function (cont)
• Review of claims denials
• Discussion of trends related to providers
• Review of relevant CMS updates and transmittals
• Determination of education and training needs

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Utilization Management is a 24/7 Activity

• Ultimately it is only the physician that can
  determine patient utilization based on the
  severity of the patients signs and symptoms and
  the medical predictability of something adverse
  happening to the patient
• Butphysician guidance and oversight is needed on
  a daily basis to ensure regulatory guidelines are
  adhered to and criteria are reviewed who does
  this?

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Utilization Management is a 24/7 Activity

• Often the admission status is clear cut due to
  patient severity and/or predictable outcomes
• Occasionally a collaboration is required between
  the physician and physician advisors may be
  case manager, nurse or others

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Evaluation of the Utilization Review/Management
Process

• Return to the plan to review goals and objectives
• Log claims denials for tracking and trending
• Assess current UM/UR methods for effectiveness by
  including inter-reliability activities in UM/UR
  meetings such as case studies
• Collaborate with the Quality Management Committee
  to determine if the mutual goal of assuring the
  most appropriate level of patient care was
  provided is met

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Assessing Your UM/UR Process

• Does your process address patient care and
  discharge planning seven days a week?
• Is there someone responsible for case management
  (e.g. discharge planning or utilization review)?
  When that individual is unavailable, who is
  responsible for this activity?
• Are there case maps, care plans or pathways
  developed for the most common DRGs?
• Are physicians supportive of case management? Do
  physicians think in terms of discharge of the
  patient and identify a specific plan of care on
  admission?

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Becoming RAC Ready

• Becoming RAC ready may require a CAH to
• Make operational changes in their Utilization
  Review process
• Make changes in their documentation requirements
  for physicians/providers and staff
• Create or revise methods of tracking claims
  denials
• Acquire tools to support utilization/level of
  care decisions
• Conduct self audits to determine training needs
• Attend training sessions and acquire educational
  materials to assist in staff and
  physician/provider knowledge

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Future Needs Related to RAC and Utilization
Management

• Survey Respondents were asked specifically what
  training and tools would assist them in
  utilization management and claims review
• 27.2 identified a need for training and
  education about utilization management in general
• 18.2 identified a need for physician training
• 13.6 identified a need for training specific to
  RAC
• 9.1 wished to have onsite in-services or
  evaluations
• 9.1 wished to have onsite in-services or
  evaluations
• 22.7 identified a need for assistance in
  developing processes to record, track and trend
  outcomes
• 9.1 wanted to acquire Milliman guidelines

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References

• Medicare Benefit Policy Manual
• www.cms.hhs.gov/manuals/downloads/bp102c01.pdf
• Observation
• Transmittal 34
• www.cms.hhs.gov/Transmittals/downloads/R147CP.pdf
• Medicare Benefit Policy Manual
• www.cms.hhs.gov/manuals/downloads/bp102c06.pdf
• Medicare Claims Processing Manual
• www.cms.hhs.gov/manuals/downloads/clm104c04.pdf

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Resources

• CAH Conditions of Participation Manual
• www.cms.hhs.gov/Manuals/IOM/list.asp
• CMS Information for CAHs
• www.cms.hhs.gov/center/cah.asp
• American Hospital Information for CAHs
• www.aha.org/aha/keyissues/rural/focus/cah.html