Hillsdale Community
Health Center
Utilization Review
Presenter: Darlene LoPresto, RN,C., BSN
Mission Statement
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The Utilization Review Department is
committed to assuring appropriate
allocation of hospital resources through
the provision of quality patient care in
the most cost effective manner.
Vision Statement
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The Utilization Review Department will
adhere to the following:
Determine medical necessity and
appropriate level of care for each
admission
Capture authorization and certification
resulting in payment by third party
payors
Vision Statement cont.
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Screen and report quality of care issues
Assure timely and cost effective care by
managing appropriate utilization of
resources
Collect and present data showing
utilization of resources and factors that
impact cost effectiveness and quality of
care
Initial Utilization Review
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All in-patient admissions, including
elective, urgent, and emergent will be
reviewed to ensure that the admission
meets InterQual Severity of Illness and
Intensity of Service criterion for the
acute in-patient setting.
Initial Utilization Review
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Admissions will be reviewed to ensure:
Each admission meets InterQual admission
criterion
Appropriate setting for the services rendered
(ICU, CCU, tertiary facility, etc)
Potential patterns of ineffective resource
utilization
Professional services furnished including
drugs & biologicals
Utilization Review
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See sample of Utilization Review
worksheet for documentation
Utilization Review
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U.R staff will perform telephonic prenotification procedures as deemed by the
insurance payor within the first business day
following the admission (Commercial,
managed medicaid, BCBS).
Some insurance companies require daily
clinical updates to obtain payment approval
Utilization Review
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The U.R. Director will be notified if any
admission does not meet InterQual criterion.
A discussion is held with the admitting
physician and then referred to the Physician
Advisor (UR Committee)for review and
determination of over-ride or denial of patient
admission (change to 23 hr stay).
Concurrent Review
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Concurrent reviews will occur on those
patients that remain in the hospital after their
initial review to determine the appropriate
level of care at a minimum of every two days.
Concurrent reviews help determine whether
the patient requires continued hospitalization
and meets InterQual Intensity of Service
criterion.
Concurrent Reviews
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Current signs & symptoms
Physician & nursing documentation
Physician orders
Results of labs, radiology, and/or surgical
procedures
Appropriateness and timeliness of
tests/procedures/consults
Environmental or social issues which may
delay timely discharge
Patient response or lack of response to
treatment
Readmission Review
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Readmission review will occur on those
patients that are readmitted within 15 days of
the previous admission (BCBS patients are
reviewed within 14 days of previous
admission)
The current and previous medical records will
be reviewed to determine whether or not the
medical records should be combined for one
admission payment.
Readmission Review
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The following three categories are assessed for
possible combination of admissions:
Premature discharge: patient is discharged without
discharge screens being met; including clinical and
level of care critieron
Planned: Patient is discharged from hospital with a
documented plan to readmit within 14-15 days for
additional services.
Continuation of Care: Patient is discharged before All
medical treatment is rendered, and care during the
second admission should have occurred during the
first admission.
23 hour admissions: Goals:
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To provide a safe alternative to emergency
department holds
To provide the opportunity for the physician
to observe the patient’s status to determine
whether or not their condition warrants
inpatient admission (or to indicate failed
observation/outpatient treatment).
To increase approvals for the inpatient
admissions that meet InterQual criteria for
the patient’s presenting signs & symptoms
23 hour Admissions
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Physician documentation of observations &
treatments are critical during this timeframe to
effectively warrant the need for inpatient
hospitalization
The Utilization Review analyst will review with
the physician whether the patient meets
inpatient or 23 hour cirteria.
Any 23 hour admissions that are changed to a
full admit and do not meet InterQual Admission
criteria will be reviewed by the UR Physician
Advisor (UR Committee), who will follow up
with the admitting physician.
23 hour Admissions
InterQual Criteria Examples
Denial of Conflicts
Hospital Issued Notice of NonCoverage
Denial of Conflicts cont.
Notification of Hospital Discharge
Appeal Rights (‘Important Notice
from Medicare’)
Denial of Conflict cont.
Expedited Review Request by
Medicare Beneficiaries
All Appeals are sent to:
MPRO
Michigan Peer Review Organization
40600 Ann Arbor Rd
Suite 200
Plymouth, MI 48170
(800) 365-5899
Utlization Review Committee
Bylaws of the Medical Staff
Description of the UR Committee
Length of Stay and DRG
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The hospital plans its fiscal budget according to DRG
(Diagnostic Related Group) length of stay. Our
current monthly budget for LOS is 3.0
Example: COPD has a DRG of 4.4 days
Each decimal point past 3.0 costs the hospital
$75,000
Goal is to maintain the DRG LOS for the diagnosis
which in turn will give us our average LOS of 3.0
Physician documentation is paramont for going
beyond a diagnotic DRG LOS
Questions/Comments
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Thank you for your participation!