All of the Following Sets Represent Criteria for Medical Necessity and Utilization Review Except
The Scenario: A patient named Sam entered the Emergency Department (ED) with abdominal pain. He was triaged and escorted to a treatment room. After an assessment, examination, lab tests and imaging, information technology was adamant Sam had appendicitis. He was scheduled for surgery the next morning for an appendectomy. Susan, the utilization review nurse, analyzed Sam's electronic medical record the side by side morning time. Susan asked herself, "Is the surgery medically necessary?" and "Tin it be performed safely in an ambulatory setting or does it require an inpatient access?"
Co-ordinate to the Centers for Medicare & Medicaid Services Glossary (2016), medical necessity is defined as "services or supplies that: are proper and needed for the diagnosis or handling of a medical condition, are provided for the diagnosis, direct intendance, and treatment of a medical condition, meet the standards of good medical practice in the local area, and aren't mainly for the convenience of the patient or md."
An Introduction to Utilization Review
Healthcare has inverse drastically in the terminal 100 years. Healthcare costs go along to rise, quality of intendance is questioned, and chronic diseases are evident now more than than ever before. These challenges must exist addressed by the industry, and effective solutions are a must.
Utilization review (UR) is ane solution to the obstacles we face today in the healthcare manufacture. Utilization review is a method used to match the patient's clinical motion picture and care interventions to evidence-based criteria such as MCG intendance guidelines. This criteria helps to guide the utilization review nurse in determining the appropriate care setting for all levels of services across the arc of patient care.
History of Utilization Review
Due to ascension costs after the induction of wellness insurance in the 1960s, President Lyndon B. Johnson and the U.S. Congress responded with programs we at present call Medicare and Medicaid. Medicare/Medicaid immune for reimbursement to the doctor for a reasonable and customary charge. Due to rising costs, and the offer of healthcare insurance from employers to employees, utilization review was presented.
Utilization review, as a process, was introduced in the 1960s to reduce overutilization of resources and identify waste. The utilization review role was initially performed by registered nurses (RNs) in the acute infirmary setting. The skillset gained popularity within the health insurance manufacture, mainly due to growing research most medical necessity, misuse, and overutilization of services. Therefore, wellness plans began to review claims for medical necessity, and the hospital length of stay (LOS). To comprise costs, some wellness plans required the physician to certify the admission and whatsoever subsequent days later the admission.
Utilization Review Process
There are three activities within the utilization review procedure: prospective, concurrent and retrospective.
- Prospective review includes the review of medical necessity for the performance of services or scheduled procedures before access.
- Concurrent reviews include a review of medical necessity decisions fabricated while the patient is currently in an acute or post-acute setting.
- Retrospective reviews involve a review of coverage later on treatment is provided.
The complete utilization review process consists of precertification, continued stay review, and transition of care.
When a patient is admitted to the facility, a first level review is conducted for appropriateness; this includes medical necessity, continued stay, level of care, potential delays in care and progression of care.
Medical necessity determines whether the infirmary admission is appropriate, justifiable and reimbursable. Continued stay determines if each day of the stay is necessary and if the level of intendance is appropriate for that day. Level of care decision identifies the most appropriate and needed level of care such as intensive or intermediate versus a medical-surgical floor level of intendance. System delays are assessed and monitored to identify whatsoever potentially avoidable delays in intendance.
Progression of care, utilizing the guideline's Optimal Recovery Grade, moves the patient through the continuum of care without delays and determines if services are appropriate, justifiable and reimbursable.
Applying the activities within the utilization review process, the nurse must accurately document the medical necessity and level of intendance based on evidenced-based criteria (such as MCG). The chart documentation must display the patient's current condition, and why the condition cannot exist safely treated outpatient, and the gamble associated if care is not provided at that level of intendance.
In determination, although this is an overview of the utilization review technique, it is important to annotation the process includes other methods such as doc 2nd level review, CMS regulatory requirements, and in some cases clinical documentation improvement. Today, utilization review is ane method used to demonstrate the quality of care and protect revenue integrity. Because quality and costs are of paramount importance, utilization review nurses must possess clinical judgment and disquisitional thinking skills to proactively mitigate overutilization and misuse of resources.
– Bharat Watson, RN, MSN, BSN, CCM, CTT+ (June 21, 2018)
The information contained in this article concerns the MCG care guidelines in the specified edition and as of the engagement of publication, and may non reverberate revisions made to the guidelines or any other developments in the subject matter after the publication date of the commodity.
Image courtesy Shutterstock/Monkey Business Images
References:
Daniels, Southward. & Hirsch, R. (2015). The Hospital Guide to Contemporary Utilization Review. HCPro.
Cesta, T. G., & Tahan, H. M. (2017). The case managers survival guide: Winning strategies in the new healthcare environs (Third ed.). Lancaster, PA: Destech Publications.
Centers for Medicare & Medicaid Services Glossary (2016, 0514) Retrieved from https://world wide web.cms.gov/apps/glossary/default.asp?Letter=M&Language=English
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Source: https://www.mcg.com/blog/2018/06/21/utilization-review-medical-necessity/
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