EDITOR'S NOTE: This is the third installment of a four part series on Utilization Management Plan.

The heart of a good utilization management (UM) plan gives operational direction to the case management team and physician advisors performing the utilization review function. According to the Wisconsin Quality Improvement Organization (QIO):

"Up-to-date policy and procedures regarding hospital admission requirements need to be in place and shared with practitioners for alternative levels of care (i.e. observation, same day surgery, swing bed). Support staff need to be available and knowledgeable regarding alternative care settings to facilitate the decision-making process when an acute hospital admission is not required. Education for practitioners, staff and families needs to be provided regarding alternative care choices. A widely accepted, current and uniform set of admission and discharge criteria needs to be available as a resource."

Below is an example of how to structure a UM plan to establish day-to-day activities of the staff and physicians charged with monitoring and managing hospital utilization.

Criteria

All staff performing first-level utilization review (UR) should be trained to use medical necessity criteria approved by the utilization review committee (URC). Annual rating of reliability of staff in criteria use is recommended as well. The most commonly used proprietary criteria are Milliman and InterQual.

Pre-Admission Review

• All patients arriving to the hospital via elective portals of entry require medical necessity criteria screening to establish status prior to undergoing a procedure or bed placement.
• All patients undergoing a procedure also shall be screened via the applicable inpatient-only list.
• If the ordered status is in conflict with the criteria and/or the inpatient-only list, the attending will be notified and solicited for additional information and clarification.
• A physician advisor may be contacted for second-level review, if necessary.
• UR staff will document the review and outcomes as established by department policy.

Admission Review

• All patients arriving to the hospital via urgent or emergent portals of entry require medical necessity criteria screening to establish status prior to undergoing a procedure or bed placement.
• All patients undergoing a procedure also shall be screened via the applicable inpatient-only list.
• If the ordered status is in conflict with the criteria and/or the inpatient-only list, the attending will be notified and solicited for additional information and clarification.
• A physician advisor may be contacted for second-level review, if necessary.
• For inpatients, a date for continued stay review will be set (not to exceed three days).
• Outpatients and outpatients with observation services will be reviewed daily.
• UR staff will document the review and outcomes as established by department policy.

Continued Stay Review

• All inpatients will be reviewed as determined by the first-level reviewer, but not more frequently than every three days.
• Medical necessity criteria will be used for screening the need for continued stay.
• Delays in care are to be entered as potentially avoidable days.
• A physician advisor may be contacted for second-level review, if necessary.

Outlier Review

• The physician advisor and UR leadership will review all outlier cases for medical necessity of continued stay.
• A weekly meeting for complex case (high cost/high length of stay) problem-solving will be established.
• Cases may be referred to the URC for review and recommendation.

Annual Focused Medical Review

• The URC will identify a known or suspected specific problem for annual review.
• Focused review will apply to all patients, regardless of payment source.
• Focused review may be based on diagnosis, procedure, admission, duration of stay, physician, ancillary services provided or delay of services, and can scrutinize all professional services performed on the hospital premises with respect to medical necessity.