Administrative Manual
COVENANT MEDICAL CENTER
2009-2011
7.08
I.
AUTHORITY
II.
Page 1 of 5
1.
The Utilization Management Plan of Covenant HealthCare System, Saginaw,
Michigan is approved by the Board of Directors, the Executive Team, the Medical
Staff Quality Improvement Committee, and the Medical Staff Executive Committee.
OBJECTIVES
1.
The purpose of the Utilization Management Plan shall be to provide for the review of professional services provided, medical necessity of admissions and continued stays, appropriateness of setting, efficient use of available health facilities and services, medical necessity of extended stays, the medical necessity of professional services including drugs and biologicals, and to promote the most efficient use of available health facilities and services.
2.
To assure that the optimal achievable quality of patient care is being provided in the most efficient and cost-effective manner possible.
3.
To review utilization information to help prioritize the use and management of limited resources.
III.
ORGANIZATION & FUNCTIONS
1.
The Medical Staff Quality Improvement Committee shall oversee the utilization management functions and report to the Medical Executive Committee. The
Committee shall be composed of seven active category medical staff members who are well-experienced in medical staff leadership. There shall also be representation from Risk Management and Clinical Resource Management. The Health Information
Management managers shall serve as an advisor to the Committee as necessary. The
Medical Staff Quality Improvement Committee meets monthly with quarterly reports presented related to utilization management. Meeting attendance is encouraged.
2.
The Utilization Management Function shall be carried out by liaisons of the medical staff, a contracted group, case management specialists, utilization review specialists, clinical documentation specialists, social workers, and pre-admission reviewers.
2.1
At least two medical staff liaisons shall be appointed by the Medical Staff Executive
Committee , e.g. intensivist, hospitalist director, chief quality officer, vice president of medical affairs .
2.2
No committee member or liaison performing review of care shall have a direct financial interest in the hospital.

UTILIZATION MANAGEMENT PLAN 2009-2011 Page 2 of 5
2.3
No committee member or liaison may conduct a review of a case in which he/she was professionally involved in the care of the patient.
2.4
Liaisons shall include those physicians identified as liaisons for the utilization management function, departmental liaisons, Medical Staff Executive Committee physicians and the Medical Staff Quality Improvement Committee physicians.
3.
The utilization management program shall include the review of Medicare, Medicaid, and all other payors with respect to the medical necessity of the admissions, duration of stays, clinical documentation, professional services furnished including drugs and biologicals, length of stay outliers, and discharge planning outcomes. When patterns of professional practice are identified, findings are considered peer review and are maintained in a confidential manner.
4.
Criteria to be utilized includes: the InterQual Level of Care criteria, payor guidelines and criteria, care path indicators, and other approved criteria.
5.
Covenant HealthCare will carry out responsibilities delegated through a formal agreement with a medical review entity.
6.
Required authorizations for admissions, continued stays and services provided will be obtained according to contract guidelines.
7.
Indicator data and trend analysis on utilization management functions shall be reported to the Medical Staff Quality Improvement Committee.
IV.
SCOPE OF REVIEW
1.
Pre-admission Review: Pre-admission reviews shall be performed prior to admission to determine the appropriateness of proposed admission.
1.1
The pre-admission reviewer will obtain information on the patient's admission diagnosis, signs, symptoms, and plan of treatment; to determine medical necessity and appropriateness of setting utilizing InterQual Level of Care criteria or other approved criteria.
1.2
Recommendations for alternative settings, scheduling options, or documentation are provided when information obtained does not coincide with screening criteria.
2.
Admission Review: Admission reviews shall be completed within one working day of admission to determine the appropriateness of admission.
2.1
The case management specialists will review the patient's medical record for documentation of diagnoses and procedures, signs, symptoms, orders, and plan of care to determine medical necessity and appropriateness of setting utilizing InterQual
Level of Care criteria or other justification, e.g. care path.
2.2
If criteria are met, case is approved for admission and next review date is assigned.
2.3
If criteria are not met for admission, attending physician is contacted.
2.3.1
If reason for admission is not apparent after contacting attending physician, the case is referred to a physician liaison for review.
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3.
Continued Stay Review: The continued stay review is performed on a regular basis according to an assigned review date. Periodic review is performed no later than 7 days after the assigned review date.
3.1
The case management specialists will review the medical record for documentation supportive of the need for continued hospital stay.
3.2
If criteria are met, case is approved for continued stay and next review date is assigned.
3.3
If criteria are not met for continued stay, attending physician is contacted.
3.3.1
If reason for continued stay is not apparent after contacting attending physician, the case is referred to a physician liaison for review.
4.
Noncertification Review: A determination that a patient’s admission or continued stay is not appropriate is made with the concurrence of two physicians.
4.1
When a liaison physician determines that an admission or continued stay is not medically necessary, the attending physician is contacted before making a determination that a stay is not medically necessary to provide the opportunity for input. .
4.1.1
If the attending physician concurs in writing with the determination of noncertification, a discharge order is obtained. The patient may appeal this discharge decision to MPRO or their payer per policy.
4.1.2
If the attending physician does not concur and additional information is not provided to certify the admission, a second physician liaison is contacted. In the case of a Title XVIII patient, MPRO is contacted to provide the second physician review except if the determination involves a pre-admission denial, in which case,
MPRO does not need to be contacted for a second physician review.
4.1.3
If the second physician liaison concurs with the determination that an admission or continued stay is not necessary, a notice of hospital requested review is issued.
4.1.4
A written notice of non-coverage is given to the patient the same day the determination has been made. Copies of the written notice are provided to the hospital, the patient or representative, the physician, and the medical review entity as required.
4.1.5
Patient is informed of appeal mechanism.
5.
Physician Liaison Reviews: Physician liaisons will review cases upon referral.
Physician advisors will provide documentation of determination and rationale. Types of cases referred may include:
5.1
Documentation on the medical record does not support the need for admission, continued stay or setting,
5.2
The plan of treatment is not congruent with the diagnosis,
5.3
The diagnosis is not adequately reflected in the documentation,
5.4
Services, treatments, tests, medications ordered do not coincide with documentation of condition,
5.5
Identification of potential quality of care issue,
5.6
Delay in provision or reporting of services,
5.7
Denial obtained from medical review entity or payor,
5.8
Readmission review, and
5.9
Other.
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6.
Focused Reviews: Focused reviews, either concurrent or retrospective, may be performed.
6.1
Focused reviews on certain diagnoses, procedures, problems, elements of care or practitioners may be performed when a concentrated review is required.
6.2
Certain diagnoses, procedures or practitioners may be excluded from review if data demonstrates a consistent absence of problems; these areas will be monitored on a periodic basis.
6.3
Payors or medical review entities may conduct focused reviews of their patients according to contract with Covenant HealthCare.
7.
Discharge Planning: Discharge planning is a collaborative process between caregivers to ensure appropriate outcomes and provision of follow-up care.
7.1
The discharge planning assessment is initially documented by the staff RN. The physician, the patient, the person acting on the patient’s behalf, or any member of the healthcare team may make identification of discharge planning needs and referrals to the case management specialist. The case management specialists also conduct their own assessment. The case management specialist collaborates with the home care specialists and program screeners, e.g. RehabCare, Transitional Care Unit, Select
Care.
7.2
The discharge plan shall be developed and documented in the medical record by a case management specialist or a social worker. The plan shall be developed in a timely manner so that appropriate arrangements can be made and to minimize delays in discharge. The plan shall be reassessed if other factors affect the continuing care needs and appropriateness of the discharge plan. The patient and/or caregiver shall participate in the discharge planning process and final plans shall be communicated to the patient or caregiver.
7.3
The discharge planning evaluation shall include an evaluation of the likelihood of patient needing post-hospital services, the likelihood a patient is to suffer an adverse health consequence if there is not adequate discharge planning, and the availability of such services. Evaluation shall be provided to patients with possible adverse health consequences as requested. Evaluation shall include the likelihood of a patient’s capacity for self-care, or the possibility of the patient being cared for in the same environment from which they arrived. Patients at risk upon discharge due to functional status, cognitive ability and family support issues are targeted for discharge planning.
7.4
Following evaluation, the initial implementation of the discharge plan shall be arranged and the patient will be prepared for discharge.
7.5
Referrals shall be made as appropriate, e.g. home care, infusion, hospice, skilled nursing, rehabilitation, long term acute, therapy, etc. If the patient is referred to another facility, agency, or outpatient service, pertinent medical information is provided to allow for follow-up care.
7.6
If a patient requires home health services, a list of agencies will be provided for patient choice. The list will be made up of those agencies that have requested to be included on the patient choice list. If a patient requires a skilled nursing facility, a list of facilities that have beds available to match the medical needs of the patient, are provided to the patient. The patient’s freedom of choice is respected.
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V.
REAPPRAISAL
1.
The Utilization Management Plan will be reviewed and approved biannually by the
Board of Directors, the Executive Team, the Medical Staff Executive Committee, and the Medical Staff Quality Improvement Committee.
Approved by:
__________________________________
Chairman, Board of Directors
__________________________________
Chief of Medical Staff
__________________________________
President, Covenant HealthCare System
__________________________________
Chairman, Medical Staff Quality Improvement
Committee
_________________
Date
_________________
Date
_________________
Date
__________________
Date
COVENANT MEDICAL CENTER