Accreditation Resource Services Newsletter
August 2020

CIHQ-ARS Blog

Utilization Review - Part Two

By: Richard Curtis
Welcome to the second in a four-part series on CMS' expectations for utilization review (UR) in an acute care hospital. In this blog, we'll discuss the required domains of a hospital's UR program. The Condition of Participation (COP) for Utilization Review at ยง482.30 form the basis for discussion.
There are three basic domains of UR review:
  • Appropriateness of admission to the hospital and the level of care into which the patient is admitted
  • The medical necessity for continued stay in the hospital, and
  • The furnishing of professional services
Appropriateness Of Admission
Admissions may be reviewed before, during or after a patient is admitted. CMS expects your hospital's UR plan to note when the review will occur. Reviews may be conducted on a sample basis, except for reviews of extended-stay cases. Many hospitals use industry accepted criteria such as InterQual or Milliman to determine if a patient's admission is appropriate.
Continued Medical Necessity
Hospitals that are paid for inpatient hospital services under the CMS prospective payment system (PPS) must conduct review of continued stays it reasonably assumes to be outliers based on extended length of stay. Criteria is also used to determine if a patient's continued stay in a hospital is medically necessary. This is probably the most important aspect of UR review.
When someone other than a physician makes an initial finding that the written criteria for extended stay are not met, the case must be referred to the UR committee or subgroup thereof which contains at least one physician. If the committee or subgroup agrees that the extended stay is not medically necessary or appropriate, the attending physician must be notified and allowed an opportunity to present his or her views and any additional information relating to the patient's needs. If a physician member of the UR committee performs the review, he or she may notify the patient's physician directly. If the patient's physician does not respond or does not contest the review, then the findings are considered final.
Furnishing of Professional Services
The UR committee must review professional services provided, to determine medical necessity and to promote the most efficient use of available facilities and services. "Professional services" includes the aspects of care rendered by laboratory personnel, physical therapists, nurses and others, as well as services provided by physicians. Examples of topics your UR committee may review are:
  • Availability and use of necessary services - underused, overuse, appropriate use
  • Timeliness of scheduling of services - operating room, diagnostic
  • Therapeutic procedures
With the advent of DRG related reimbursement, concerns around over-utilization of services has significantly diminished. The days of ordering too many tests and consults have pretty much gone by the wayside. Nowadays, the concern is under-utilization of services. Are hospitals cutting the corner a little too tightly in an effort to reduce cost and maximize dollar savings? Many UR committees now monitor indicators for under-utilization such as:
  • Readmissions within a defined time frame (e.g. within 48 hours for the same diagnosis)
  • Unscheduled returns to a higher level of care
  • Unscheduled returns to surgery,
  • Etc.
Join me in a couple of weeks for Part Three in this series as we look at CMS' expectations around denial of continued stay.
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