Utilization Management
Learning Objectives
Upon completion of this section the participant will
be able to:
• Define Utilization Management.
• Understand the Utilization Management
process in a hospital setting.
• Describe the types of Utilization
Management reviews.
• Understand Quality Monitoring, Risk
Monitoring, and Avoidable Days
Monitoring.
What is Utilization Management?
• Utilization Management (UM) is a process for
assessing the delivery of healthcare services to
determine if patient care is medically necessary,
appropriate, efficient and meets quality
standards.
• UM in a hospital setting includes the formal
review of hospital inpatient or observation status
patients on a prospective, concurrent, or
retrospective basis.
The UM process considers the following:
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How sick is the patient?
What is the physician’s intent?
What are we doing for the patient?
What has been done in the outpatient setting?
What is the discharge plan?
UM Benefits to the hospital:
• Cost Savings
• Decreased Length of Stay (LOS)
• Decreased denials
• Appropriate level of care
• Decreased health care costs
UM Benefits to the patient:
• Timely and efficient discharge.
• Patient safety: Increased risk of hospital
acquired infections, skin breakdown, etc.
with prolonged acute inpatient stays. The
Institute of Medicine’s 2000 Report
estimated that up to 98,000 hospital
patients die each year due to medical
errors.
UM Assignments in an Acute
Hospital Setting
• Geographic Based: The case manager’s
assignments are unit specific.
• Payer Based: The case manager’s assignments
are based on the patient’s payer source, e.g.
Medicare, Medicaid, Managed Care or
uninsured.
• Physician Based: The case manager’s
assignments are based on patients with the
same attending MD or a hospitalist model.
Geographic Based UM Assignments
Pros
Cons
•Builds working relationship with
•Decreased continuity with patient
unit’s nursing, ancillary and clerical transfers to other units.
staff.
•May increase efficiency of the
utilization management process
•Efficient and effective discharge
planning with usually one Case
Manager.
•Decreased customer service
satisfaction with physicians
dealing with multiple case
managers.
Payer Based UM Assignments
Pros
Cons
•Consistency in the review process •The case manager may have
for specific payers with the
patients in many different locations
possible benefit of decreased
in the hospital.
denials.
•Relationship building with the
payer reviewer.
•Relationships with nursing unit
staff may be fragmented.
•Understanding of specifics of
payer contracts.
•The payer reviewer may need to
work with multiple Case Managers
for discharge planning.
•Travel time to different hospital
units.
Physician Based UM Assignments
Pros
Cons
•Increased physician satisfaction
from working with one case
manager.
•The case manager may have
patients in many different locations
in the hospital.
•Potential for more effective and
efficient working relationship with
physicians.
•Relationships with nursing unit
staff may be fragmented.
•Clearer understanding of
physician practice patterns.
•The payer reviewer may need to
work with multiple Case Managers
for discharge planning.
•Travel time to different hospital
units.
The Use of Criteria in the Utilization
Management Process
• Most UM in the hospital setting involves the use of
written or computerized nationally recognized guidelines
such as McKesson’s InterQual® Criteria or Milliman
Care Guidelines®.
InterQual® Criteria
• InterQual® developed first set of criteria for
managing the care of acute inpatient
hospitalizations in 1978.
• InterQual® Acute Criteria enables the case
manager to determine if the care is clinically
indicated and at the appropriate level of care.
• The use of InterQual® Acute Criteria includes
the selection of a criteria subset that most
clearly identifies the patient’s most prominent
presenting clinical findings.
InterQual® Severity of Illness Criteria
• InterQual® Level of Care Criteria includes
Severity of Illness (SI) Criteria.
• SI criteria consist of clinical indicators of the
patient’s illness and clinical presentation.
• SI criteria may include clinical findings, imaging
results, EKG findings, and/or laboratory findings.
InterQual® Intensity of Service
Criteria
• InterQual® Level of Care Criteria also includes
Intensity of Service (IS) Criteria.
• IS Criteria consists of the actual patient care
being delivered at a specific level of care.
• IS Criteria may include monitoring, specific IV
medications, and other therapeutic services.
Milliman Care Guidelines®
• Milliman Care Guidelines® are evidence-based
clinical guidelines including care pathways,
quality measures, and integrated medical
evidence that are used by case managers to
make decisions about the care of patients.
Managed Care Guidelines/Criteria
• Managed Care Organizations (MCOs) may have
developed their own specific criteria for different
procedures and/or diagnoses.
• MCOs may opt not to use only one specific set
of criteria or guidelines for approving inpatient
stays.
Review Questions
1. What is one benefit to the hospital that
utilization management provides?
a) Increased cost of care
b) Increased LOS
c) Decreased denials
2. Name one nationally recognized utilization
management criteria or guidelines:
a) Center for Disease Control criteria
b) InterQual® Criteria
c) Patient Outcome Guidelines
Answer Key
1. C
2. B
Utilization Management
How to do a Review
Point of Entry Review Process
• Direct admission
• Surgical admission
• Emergency Department (ED) admission
Types of Reviews
• Precertification review – Occurs before an
admission or surgical event. Apply the
precertification criteria your facility uses.
Types of Reviews
Examples of pre-certification reviews:
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Elective surgeries
Planned direct admissions
Facility-to-facility transfers
Types of Reviews
Concurrent reviews:
• Admission concurrent review
• Continued stay concurrent review
Types of Reviews
• Admission concurrent review: Performed within
24 hours of admission.
• Continued stay concurrent review: Review
completed within the time frame designated per
your policy while the patient is still in your facility.
• Retrospective review: Occurs after discharge.
Direct Admission Review
• Review MD order sheet with admission
diagnosis and interventions.
• Apply your criteria.
• Call MD for further information if needed.
• Check for correct level of care.
Elective Surgical Admission Review
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Check for preauthorization status.
Check for number of days approved by MCO.
Check for correct level of care.
If unclear, call MCO.
Emergency Department Admission
Review
• Review ED record and EMS trip sheet.
• Speak with ED MD and nurse caring for patient
for further information if needed.
• Apply your criteria.
• Check for correct level of care.
Concurrent Admission Review
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Begin review with point of entry documentation
Review medical record to include:
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MD orders
Progress notes
Lab results
Graphic sheets
Nurses’ notes
Medication records
Interdisciplinary team notes
Apply specific criteria set
Concurrent Admission Review
• Ask yourself these questions:
• Does this patient meet criteria to be
observation or inpatient?
• Is the patient at the right level of care?
• If all answers are YES – document your proof of
criteria in your documentation system.
• Schedule next review per your policy guidelines.
Concurrent Admission Review
• If the answers to the questions were NO:
• Call attending MD for more information.
(Insert your specific facility guidelines here)
Continued Stay Review Process
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Include a daily review for date of last review to
present.
Review medical record as previously stated.
Continued Stay Review Process
• Apply criteria
• Is patient still meeting criteria?
• If YES: Schedule next review in the future
according to policy.
• If NO: Review interdisciplinary notes to assist
in discharge plan.
• Call attending MD for further information.
Continued Stay Review Process
• Speak with your interdisciplinary team, patient
and family regarding discharge plan.
• If the attending MD is not agreeable with
discharge plan, insert your policy and
procedure for addressing this matter.
• Assign avoidable days.
Continued Stay Review Process
• If the patient and/or family is not agreeable to
the discharge plan, follow your institution
guidelines for denial letter or Medicare appeal
process if applicable.
• Document per your facility process guidelines.
Review Questions
1. True or False: For a continued stay review you
should include a daily review for date of last
review to present.
2. True or False: For an ED admission review you
can include the EMS sheet as part of your
review.
Answer Key
1. True
2. True
Condition Code 44
• The CMS Manual, Chapter 1, Section 50.3,
describes when and how a hospital may change
a patient’s status from inpatient to outpatient,
and further describes the appropriate use of
Condition Code 44.
Condition Code 44
• In some instances, a physician may order a
beneficiary to be admitted to an inpatient bed,
but upon reviewing the case later, the hospital’s
utilization review committee determines that an
inpatient level of care does not meet the
hospital’s admission criteria.
Condition Code 44 (Cont’d)
• In cases where a hospital utilization review
committee determines that an inpatient
admission does not meet the hospital’s inpatient
criteria, the hospital may change the patient’s
status from inpatient to outpatient.
Condition Code 44 (Cont’d)
To fall under this rule all of the following conditions
must be met:
• The change in status from inpatient to
outpatient is made prior to discharge.
• The hospital has not submitted a claim to
Medicare.
• A physician concurs with the utilization review
committee’s decision.
• The physician concurrence is documented in
the medical record.
Condition Code 44 (Cont’d)
(Insert your facility policy for Condition Code 44)
Other Types of Monitoring
• Quality monitoring
• Risk monitoring
• Avoidable day monitoring
Quality Monitoring
“Quality monitoring are activities designed to
monitor, prevent, and correct quality deficiencies.”
POWELL’S (2000) Advanced Case Management Outcomes and
beyond, Philadelphia: Lippincott Williams and Wilkens
Quality and Risk Monitoring
• While conducting a UM review, the Case
Manager should be on the look out for patient
care situations that are high risk or problem
prone.
• The Case Manager should identify and report
quality of care or risk issues to the appropriate
department at your facility.
• Evaluate readmissions carefully for potential
quality issues.
Quality Monitoring
• The Case Manager functions as the patient
advocate, being proactive in addressing issues
before they become problems.
• The Case Manager monitors quality indicators to
identify potential problems early on in the
hospital stay.
• The Case Manager should carefully assess
readmissions.
Quality Monitoring
(Insert your Quality policy.)
Review Questions
1. The Case Manager functions:
a)
Patient advocate
b)
Monitor quality indicators
c)
Being proactive in addressing issues
d)
All of the above
Answer Key
1. All of the above
Risk Monitoring
“Risk Management is the process of making and
carrying out decisions that will minimize the
adverse effects of accidental losses. Risks and
their prudent management are viewed as matters
of patient safety.”
•CMSA Core Curriculum for Case Management 2001,
Lippincott
Risk Monitoring
• The Case Manager will notify Risk Management
when potential patient/family situations arise.
• The Case Manager notifies the Risk Manager as
soon as an incident occurs.
• The Case Manager will notify Risk Management
of any potential law suits.
Risk Monitoring
(Insert your Risk Management plan.)
Review Questions
1. True or False: Risks and their prudent
management are viewed as matters of patient
safety.
2. True or False: Case Management should be
on the lookout for situations that are low risk
and happen infrequently.
Answer Key
1. True
2. False
Avoidable Days
Identifying and Recording Avoidable Days
Overview
Case Management is key in identifying delays
in patient treatment and hospital days as well
as concerns relating to patients during their
hospital stay.
Definition of an Avoidable Day
An occurrence or event during patient’s hospital
stay that causes an increase in the patient’s
length of stay or a delay in discharge.
Avoidable Day Types
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Physician Delays
Hospital or Department Delays
Continuum/Discharge Delays
Avoidable Day Reporting
(Insert your avoidable day reporting
process.)
Physician Avoidable Days
Definition: A delay in care related to Physician
performance.
Example: Patient is not meeting acute care
criteria and no discharge order written.
Hospital/Department Avoidable
Days
Definition: A delay in care related to a hospital
breakdown in process.
Example: Physician orders a heart catheterization,
but it is not performed for 2 days due to Cath Lab
scheduling.
Continuum/Discharge Avoidable
Days
Definition: A delay in care not related to the
physician or hospital, yet by an outside resource or
provider.
Example: Patient has order to be discharged to
Skilled Nursing Facility and there are no beds
available.
Avoidable Day Reporting
Avoidable Day Reports are a useful tool for the
management team and the organization.
Avoidable Day Reporting
• Avoidable day tracking provides us with the
ability to build and generate standardized
reports.
• Avoidable day tracking gives us the opportunity
to identify trends.
Avoidable Day Reports (Cont’d)
(Insert examples of your avoidable day types
and reasons)
Positive Outcomes from Avoidable
Day Reports
Through the tracking and trending of delays by
type and reason we have been able to:
• Work with physicians to provide education
as needed.
• Identify areas for improvement.
• Open communication with outside
providers.
Positive Outcomes from Avoidable Day
Reports (Cont’d)
Through the tracking and trending of delays by
type and reason you will be able to:
(Insert your outcomes)
Review Questions
1. True or False: An avoidable day is an
occurrence or event during a patient’s hospital
stay that causes an increase in the patient’s
length of stay or delay in discharge.
2. True or False: A physician delay is a delay in
care related to physician performance.
Answer Key
1. True
2. True
References
• CMSA Standards of Practice for Case
Management (2002), Little Rock, AR CMSA
• Leaders Guide to Hospital Case Management
(1998) Steffani/Ramey
• Interqual® Level of Care – McKesson Health
Solutions 2007
• Milliman® Care Guidelines
www.careguidelines.com