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1
A.
Overview and Definitions
B. Types of Reviews
C. Utilization Review Criteria
- Interqual
-
Milliman Care Guides
D. Medical Necesity. What is it?
E. Cost Effectiveness.
What is it? How is it applied?
F. Quality and Access
G. Giving a Review
PART
2 (coming in September)
H. Levels of Care - Criteria & Costs
I. Certifications
and Training -
CPUR
and CPUM
J. Qualifications & Job Descriptions
K. Timely Discharges/Delayed Discharges
L. Physician Issues
M.
Denials
N. Miscellaneous
- Perceived
Abuses
- Observation
Patients
The
Advocates Guide to Managed Care –
the Utilization Review Process
Utilization
Review Provisions
The
utilization
review criteria must be based on sound, up-to-date clinical
criteria and must be applied consistently in all appropriate reviews.
Utilization Review Provisions:
• Medical Necessity
• Assessing Utilization of Health Services
• Who Conducts Utilization Reviews
• Time Limits for Review
• Utilization Review Procedures
Definition:
Utilization Review: A system designed to monitor the use
of, or evaluate the medical appropriateness, efficacy
or efficiency of health care services, procedures, providers or
facilities. utilization review may include ambulatory review,
case
management, certification, concurrent
review, discharge planning, prospective
review, retrospective
review or second opinions
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Medical
Necessity - Definition
"Medical necessity" or "medically necessary"
relates to those services and supplies that are required for
diagnosis or treatment of illness or injury OR, which, if
omitted, would adversely affect the patient’s condition.
Definition:
Medical Necessity:
Each HMO
must have a utilization
review system that collects data and assesses the use
of health care services. Specifically, the system must have
mechanisms to evaluate medical necessity, as well as the:
- appropriateness,
- effectiveness
and
- efficiency
of health services.
The
Effects of Prospectively Screening Emergency Department Admissions
for Level of Care
While requiring incremental resources and process changes, concurrent
UR admission screening dramatically reduces denials.
Utilization
Management Can Negatively Impact Healthcare Quality and Access
- Robert Wood Johnson Foundation Report
Tips
to Help Take the Hassle Out of Inpatient Utilization Review
| |
Toni
Cesta, PhD, RN, FAAN
Director Case Management
St. Vincents Catholic Med'l Centers NY |
Elaine
Cohen, EdD, RN, FAAN
Dir Case Management and
Assoc Professor
Univ Colorado Health Sciences Center |
Tim
Field, PhD,
Author, Consultant, Educator and Vocational
Expert |
CMSA's
2004
Case Manager of the
Year
Major Melanie Prince,
RN, CCM |
Julie
Smart,
Ph.D, CRC, NCC, LPC, ABDA,
CCFC
Professor & Director
Rehab Counselor Education Program
Utah State University |
Peggy
Rossi, BSN, MPA, CCM, CPUR
Director of Utilization and Case Mgmt
Catholic Healthcare West
California |
Vivian
Campagna, RN, CCM
Director Case Management
St. Clare's Hospital & Health Center,
New York, NY |
| Interested
in being part of our
Advisory Board? Contact us
1-866-850-5999 |
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