January 3, 2012

The Essential Requirements for Effective Utilization Review

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EDITOR’S NOTE: This is the final installment in a four-part series on the Utilization Management Plan.

 

Concurrent denial management, information management, conflict of interest analysis, confidentiality and plan evaluation, amendments and revisions are the final required elements in a strong and compliant utilization management (UM) plan.

 

Concurrent denial management:

 

Medicare: https://www.cms.gov/BNI/05_HINNs.asp Hospitals provide hospital-issued notices of noncoverage (HINNs) to beneficiaries prior to admission, at admission or at any point during an inpatient stay if the hospital determines that the care the beneficiary is receiving or is about to receive is not covered because it is:

 

  • Not medically necessary;
  • Not delivered in the most appropriate setting; or
  • Custodial in nature.
  • HINN 10, also known as the notice of hospital-requested review (HRR), should be issued by hospitals to beneficiaries in original Medicare whenever a hospital requests QIO review of a discharge decision without physician concurrence.
  • HINN 11, which is used for noncovered items or services provided during an otherwise covered stay, and its instructions have not yet been incorporated into Chapter 30 of the Online Claims Processing Manual.
  • HINN 12 should be used in association with the hospital discharge appeal notices to inform beneficiaries of their potential liability for a noncovered continued stay.
  • The preadmission/admission HINN, used prior to an entirely noncovered stay, is also known as HINN 1 and replaces HINNs 1 and 9.

 

As noted from the above CMS website post, the hospital is responsible for delivery of the HINNs for Medicare beneficiaries. The UM plan should address when, how and by whom the notices will be delivered and managed. A separate concurrent denials policy may be established and simply referenced in the UM plan.

 

Medicaid: Requirements vary from state to state for notification of denial of care and/or termination of benefits. Reference your own state's requirements for inclusion in the UM plan.

 

Commercial Payers: It is the responsibility of the payer to inform the patient and/or the patient's family, attending physician and facility department responsible for utilization review of adverse determinations. The responsible utilization review personnel should facilitate physician-to-physician communication as appropriate.

 

Information Management: The UM plan should establish the following data management expectations for the utilization review function.

  • Coordination and maintenance of data to address issues of overutilization, underutilization and medical necessity;
  • The use of automated information management systems to optimize efficiency;
  • Maintenance of utilization review files and results, kept separately from the medical record;
  • The collection and aggregation of data for tracking and trending reports; and
  • Maintenance of minutes of each utilization review committee meeting and distribution to the established chain of authority.

Conflict of Interest

 

As noted in the CMS Conditions of Participation, physicians may not participate in the review of cases in which he/she has been or anticipates being involved professionally. Physicians having a direct or indirect financial interest in the case(s) being reviewed also may not participate in utilization review activity.

 

Confidentiality

 

The UM plan should contain a confidentiality statement that ensures the strict confidentiality of all reports, patient review forms and other data presented at meetings. This statement should be reviewed by your compliance officer and legal team for completeness.

 

UM Plan Evaluation, Amendment and Revisions

 

The hospital UM plan should be reviewed and updated or modified as necessary based upon the ongoing annual evaluation of utilization review activities. The reviewed and/or revised plan annually should be submitted for approval. An evaluation of the entire UM program and its effectiveness in allocating resources must be documented, with the results reported to the board of trustees annually.

 

The quote below is from the latest CMS State Operations Manual, and it provides guidance to state surveyors for review of the UM plan and the utilization review committee.

 



 

State Operations Manual Appendix A - Survey Protocol, Regulations and Interpretive Guidelines for Hospitals (Rev. 75, 12-02-11):

 

"The hospital UR plan should include a delineation of the responsibilities and authority for those involved in the performance of UR activities. It should also establish procedures for the review of the medical necessity of admissions, the appropriateness of the setting, the medical necessity of extended stays and the medical necessity of professional services.

 

Survey Procedures §482.30

 

  • Determine that the hospital has a utilization review plan for those services

furnished by the hospital and its medical staff to Medicare and Medicaid patients.

  • Verify through review of records and reports, and interviews with the UR

chairman and/or members, that UR activities are being performed as described in

the hospital UR plan.

  • Review the minutes of the UR committee to verify that they include dates,

members in attendance (and) extended-stay reviews with approval or disapproval noted

in a status report of any actions taken."

 

So be prepared to present your UM plan not only for review and approval, but to deliver proof that the plan is being followed and implemented as written.

 

About the Author

 

Donna McLean, RN, MBA, CMAC, is president and co-founder of DSE Associates - Healthcare Case Management Solutions. Donna's 25 years of firsthand experience in providing healthcare services qualifies her to understand the needs and requirements of clients in the healthcare arena.

 

Contact the Author

 

mc.fam@comcast.net

 

To comment on this article please go to editor@racmonitor.com

 

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