Utilization management in healthcare is commonly thought of as a strategy that payers employ to control resource use within physician offices and hospitals to keep healthcare costs down. However, hospital utilization management programs are also an essential part of a provider organization’s revenue cycle, helping to prevent unnecessary costs and claim denials.<\/p>\n
According to the Healthcare Financial Management Association (HFMA), healthcare utilization management is the “integration of utilization review, risk management, and quality assurance into management in order to ensure the judicious use of the facility's resources and high-quality care.”<\/p>\n
Comprehensive hospital utilization https:\/\/clinicaldocs.mystrikingly.com\/<\/a> review and management are key to preventing denials and lodging successful requests for appeals.<\/p>\n Medicare and Medicaid use Recovery Audit Contractors (RACs) to review claims and detect improper reimbursement for incorrectly coded services, non-covered services, and duplicate services.<\/p>\n RACs can deny claims and recover improper reimbursement by reviewing medical records to determine if healthcare utilization was appropriate.<\/p>\n The average number of medical record requests and denials from Medicare RACs is on the rise, the American Hospital Association (AHA) reported.<\/p>\n Hospitals reported receiving an average of 1504 medical records requests by the end of 2016, up from 1424 in the first quarter of 2014. <\/p>\n Utilization management and review can prevent hospitals from receiving retrospective claim denials and being forced to relinquish money already received.<\/p>\n Hospital utilization management programs will also become increasingly important as organizations take on value-based reimbursement models. Prior authorizations and medical record reviews are key for providers who are at risk for over- or underutilization.<\/p>\n Implementing a strong utilization management program to verify that patients are receiving the right care at the right time will ensure that hospitals are delivering appropriate, cost-efficient care.<\/p>\n Hospital utilization management encompasses all activities that a hospital performs to ensure care is appropriate and necessary.<\/p>\n Stakeholders often use the term “utilization review” interchangeably with “utilization management.” However, utilization review is just one of the processes included in hospital utilization management programs.<\/p>\n Whereas utilization management is the integration of all activities, utilization review is “the process where organizations determine whether health care is medically necessary for a patient or an insured individual,” explained URAC, formerly known as the Utilization Review Accreditation Commission.<\/p>\n "Utilization management is the integration of utilization review, risk management, and quality assurance into management in order to ensure the judicious use of the facility's resources and high-quality care."<\/p>\n<\/blockquote>\n Utilization review contains three types of assessments: prospective, concurrent, and retrospective.<\/p>\n A prospective review<\/strong> assesses the need for healthcare services before the service is performed. Providers must often submit prior authorizations to health plans under this utilization review process to ensure the most appropriate services are being rendered.<\/p>\n For concurrent reviews<\/strong>, services are reviewed during the hospitalization or care episode. The review encompasses case management activities, such as care coordination, discharge planning, and care transitioning, and primarily focuses on the appropriateness of length of stay and initial discharge plans.<\/p>\n Retrospective review<\/strong> is the process of assessing appropriateness of procedures, settings, and timings after the services have been rendered. Hospitals typically have a specialized nurse or claims expert perform retrospective reviews to ensure claim submissions contain complete, correct billing codes for services provided.<\/p>\n Health plans and public payers also use retrospective review to ensure accurate reimbursement. Hospitals may see a claim denial because a retrospective review showed that a claim was not properly billed or the patient did not undergo the most appropriate course of treatment.<\/p>\n Utilization management should include the three types of review to ensure all care delivered is appropriate. Hospitals should also develop a program with detailed procedures, policies, and staff responsibilities to implement truly effective utilization management strategies.<\/p>\n CMS provides a basic template for creating a hospital utilization management program as part of the Medicare and Medicaid Conditions of Participation.<\/p>\n The federal agency mandates that any hospital receiving Medicaid or Medicare reimbursement must implement “a utilization review 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.”<\/p>\n A hospital utilization review plan should outline the responsibilities and authorities of all staff members performing utilization review activities. The plan must also detail the procedures for evaluating the medical necessity of admissions, extended stays, and professional services, as well as reviews of the appropriateness of care settings.<\/p>\n Utilization review can be conducted on a sample basis, CMS added.<\/p>\n However, hospitals that receive reimbursement under the Inpatient Prospective Payment System (IPPS) must also conduct utilization reviews for duration of stays in outlier cases with extended lengths of stay. For professional services, the hospitals must conduct reviews for outlier cases with excessively high healthcare costs.<\/p>\n The utilization review committee is another key component of the required utilization management program. CMS requires that hospitals designate at least two practitioners to carry out utilization review responsibilities. At least two of the committee members must also be doctors of medicine or https:\/\/64ba8056e53b1.site123.me\/<\/a> osteopathy.<\/p>\n Hospitals are increasingly turning to physician advisors to fill this role and spearhead utilization management programs.<\/p>\n Physician advisors are providers with specific experience in reimbursement and health policies. They act as liaisons between clinical and non-clinical staff to support utilization review, clinical documentation improvement, and claim denials management, explained Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADV, physician advisor at ProHealth Care in Wisconsin.<\/p>\n “At the end of the day, training.farmingadviceservice.org.uk<\/a> we're talking about medical necessity, which we are finding is something that in many instances cases requires a physician advisor of some sort to make the final determination,” she said.<\/p>\n Physicians may not have medical necessity guidelines at the forefront of their thoughts when delivering care, and case managers may not be equipped with policies from all contracted payers to make the best judgment on medical necessity.<\/p>\n “You need to have a physician who’s looking at it with that eye of case management and utilization, which is not something that all practicing physicians have, nor should they because their focus should be on the medicine,” Ugarte Hopkins said.<\/p>\n In addition to physicians, case managers and nurses are staples of the utilization management program team. Utilization review is typically part of case management, which is primarily a nurse’s responsibility at hospitals.<\/p>\n However, case managers do not necessarily need a medical degree. Care managers and care coordinators are still key utilization management staff because they help patients to navigate the healthcare system in a manner that results in high-quality, cost-efficient care.<\/p>\n “You need to have a physician who’s looking at it with that eye of case management and utilization."<\/p>\n<\/blockquote>\n Hospitals can either form their own utilization review committees or outsource the task to a local medical society or an approved organization, such as an accredited Utilization and Quality Control Quality Improvement Organization. Neighboring hospitals can also pool their resources to create a shared utilization review committee.<\/p>\n Utilization review committees are responsible for making the final judgment on medical necessity for services in question.<\/p>\n CMS requires that at least two members of the committees make the determination unless the admitting provider agrees that services were medically unnecessary or the provider fails to argue their case for treatment. In those cases, only one utilization review committee member is required for making the judgment. <\/p>\n Medicare and Medicaid conditions of participation emphasize that a non-physician may not<\/em> make a final determination on whether a patient’s stay is medically necessary or appropriate.<\/p>\n Hospitals only have to review a sample of patient cases to comply with CMS regulations, but utilization management “should run seven days a week, 365 days a year,” suggested Ralph Wuebker, MD, MBA, former Chief Medical Officer (CMO) of consulting firm Executive Health Resources and current CMO of Optum360.<\/p>\n Concurrent utilization reviews and case management should occur for all medical cases placed in hospital beds, he explained. All cases that do not pass the criteria for appropriate utilization should be referred to a physician advisor.<\/p>\n Physician advisors should then review the case, discuss the situation with the admitting physician, and make recommendations based on national-level and hospital-level utilization review standards.<\/p>\nEXPLORING THE KEY COMPONENTS OF HOSPITAL UTILIZATION MANAGEMENT<\/strong><\/h3>\n<\/p>\n
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IMPLEMENTING A HOSPITAL UTILIZATION MANAGEMENT PROGRAM<\/strong><\/h3>\n<\/p>\n
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BEST PRACTICES FOR UTILIZATION MANAGEMENT AND REVIEW<\/strong><\/h3>\n<\/p>\n