What Is Utilization Review and Why Is It Important in Healthcare
The Scenario: A patient named Sam entered the Emergency Department (ED) with abdominal pain. He was triaged and escorted to a treatment room. After an assessment, examination, lab tests and imaging, it was adamant Sam had appendicitis. He was scheduled for surgery the next morning for an appendectomy. Susan, the utilization review nurse, analyzed Sam's electronic medical record the next forenoon. Susan asked herself, "Is the surgery medically necessary?" and "Can it be performed safely in an ambulatory setting or does it require an inpatient admission?"
According to the Centers for Medicare & Medicaid Services Glossary (2016), medical necessity is divers as "services or supplies that: are proper and needed for the diagnosis or handling of a medical condition, are provided for the diagnosis, direct care, and handling of a medical condition, meet the standards of good medical practice in the local area, and aren't mainly for the convenience of the patient or physician."
An Introduction to Utilization Review
Healthcare has inverse drastically in the last 100 years. Healthcare costs continue to rise, quality of care is questioned, and chronic diseases are evident now more than always before. These challenges must be addressed by the industry, and constructive solutions are a must.
Utilization review (UR) is ane solution to the obstacles we face today in the healthcare industry. Utilization review is a method used to match the patient'southward clinical picture and care interventions to prove-based criteria such as MCG care guidelines. This criteria helps to guide the utilization review nurse in determining the appropriate care setting for all levels of services across the arc of patient care.
History of Utilization Review
Due to ascent costs after the consecration of health insurance in the 1960s, President Lyndon B. Johnson and the U.S. Congress responded with programs we at present call Medicare and Medicaid. Medicare/Medicaid allowed for reimbursement to the physician for a reasonable and customary accuse. Due to rising costs, and the offer of healthcare insurance from employers to employees, utilization review was presented.
Utilization review, as a process, was introduced in the 1960s to reduce overutilization of resources and identify waste. The utilization review function was initially performed past registered nurses (RNs) in the acute infirmary setting. The skillset gained popularity within the wellness insurance industry, mainly due to growing research near medical necessity, misuse, and overutilization of services. Therefore, health plans began to review claims for medical necessity, and the hospital length of stay (LOS). To contain costs, some health plans required the physician to certify the access and any subsequent days later on the admission.
Utilization Review Process
At that place are three activities within the utilization review process: prospective, concurrent and retrospective.
- Prospective review includes the review of medical necessity for the performance of services or scheduled procedures earlier admission.
- Concurrent reviews include a review of medical necessity decisions made while the patient is currently in an acute or post-acute setting.
- Retrospective reviews involve a review of coverage after treatment is provided.
The complete utilization review process consists of precertification, connected stay review, and transition of care.
When a patient is admitted to the facility, a first level review is conducted for ceremoniousness; this includes medical necessity, continued stay, level of intendance, potential delays in care and progression of care.
Medical necessity determines whether the hospital access is appropriate, justifiable and reimbursable. Continued stay determines if each day of the stay is necessary and if the level of intendance is appropriate for that day. Level of care determination identifies the most appropriate and needed level of care such equally intensive or intermediate versus a medical-surgical floor level of care. Organisation delays are assessed and monitored to identify whatever potentially avoidable delays in care.
Progression of care, utilizing the guideline's Optimal Recovery Course, moves the patient through the continuum of care without delays and determines if services are appropriate, justifiable and reimbursable.
Applying the activities inside the utilization review procedure, the nurse must accurately document the medical necessity and level of care based on evidenced-based criteria (such equally MCG). The chart documentation must display the patient'due south electric current condition, and why the condition cannot exist safely treated outpatient, and the risk associated if intendance is non provided at that level of care.
In determination, although this is an overview of the utilization review technique, it is important to notation the process includes other methods such as dr. second level review, CMS regulatory requirements, and in some cases clinical documentation improvement. Today, utilization review is one method used to demonstrate the quality of intendance and protect revenue integrity. Because quality and costs are of paramount importance, utilization review nurses must possess clinical judgment and critical thinking skills to proactively mitigate overutilization and misuse of resources.
– India Watson, RN, MSN, BSN, CCM, CTT+ (June 21, 2018)
The information contained in this commodity concerns the MCG care guidelines in the specified edition and as of the date of publication, and may not reflect revisions made to the guidelines or any other developments in the subject matter afterwards the publication appointment of the article.
Image courtesy Shutterstock/Monkey Business concern Images
References:
Daniels, S. & Hirsch, R. (2015). The Hospital Guide to Gimmicky Utilization Review. HCPro.
Cesta, T. One thousand., & Tahan, H. M. (2017). The instance managers survival guide: Winning strategies in the new healthcare environment (Third ed.). Lancaster, PA: Destech Publications.
Centers for Medicare & Medicaid Services Glossary (2016, 0514) Retrieved from https://www.cms.gov/apps/glossary/default.asp?Letter=M&Language=English
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Source: https://www.mcg.com/blog/2018/06/21/utilization-review-medical-necessity/#:~:text=Utilization%20review%20is%20a%20method,the%20arc%20of%20patient%20care.
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