Accreditation Resource Services Newsletter
September 2020


Utilization Review - Part Four

By: Richard Curtis
Welcome to the last in a four-part series on CMS' expectations for utilization review (UR) in an acute care hospital. In this blog, we'll discuss how to prepare for a review of your UR program during a survey. The Condition of Participation (COP) for Utilization Review at ยง482.30 form the basis for discussion.

Written Program

Your hospital should have a written UR program that is current and approved by the governing body. We recommend that the written document address at least the following:
Scope of the Program
The UR program should address at least the three domains of review;
  • Appropriateness of admission
  • Continued medical necessity of inpatient stay
  • Review of professional services
The document should address how your hospital identifies potential cases for review, the metrics (criteria) used, and who is responsible for assuring that reviews occur.
Composition of the UR Committee
The written document should outline the composition and structure of your UR Committee, specifically addressing the requirement for at least two physician members who are either an MD or DO. In addition, the meeting frequency and reporting relationship to the hospital and/or medical staff and governing body should be documented. The language should address conflict of interest concerns (see below)
Review and Appeal Process for Denial of Admission or Continued Stay
CMS is prescriptive in how a hospital is to approach denial of admission or continued inpatient stay. We recommend that the language in the UR program be taken directly from the interpretive guidance in Appendix A of the State Operations Manual by CMS.

Conflict of Interest Disclosure

Remember that CMS states that reviews should not be conducted by any individual who;
  • Has a direct financial interest (for example, an ownership interest) in that hospital; or
  • Was professionally involved in the care of the patient whose case is being reviewed.
We recommend that each member of the UR committee sign a conflict of interest statement at the time of initial appointment noting his or her understanding of this requirement and responsibility to recuse himself or herself from a review if necessary.

Minutes of the UR Committee

There should be minutes kept of each UR Committee meeting, along with an agenda and roster of attendance. Be sure to clearly note physician representation at the meeting. While CMS could request minutes from any time-frame, we recommend that at least the last 12 months of minutes be available for review at any time.
Also, if your hospital is part of a health-system and your UR Committee performs its function for multiple hospital, then the minutes clearly need to show the UR function is being performed for each individual facility.
While not required, we recommend that the structure of the minutes be organized around the three required domains of review. This will make it obvious to surveyors that you are covering your bases.

Denial of Admission/Continued Stay

If a patient has been denied admission or continued stay, documentation should be maintained. The documentation should clearly show that the procedures outlined in your UR program were followed. We recommend that a separate file be maintained for each denial. The file should contain all relevant documentation - including correspondence to/from the patient and attending physician. While CMS surveyors do not determine whether reviews were appropriately adjudicated, they can assess whether you followed your policy.
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