Discuss Three Steps in Medical Necessity and Utilization Review
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, it was determined Sam had appendicitis. He was scheduled for surgery the adjacent morning for an appendectomy. Susan, the utilization review nurse, analyzed Sam's electronic medical record the next morning. Susan asked herself, "Is the surgery medically necessary?" and "Tin it be performed safely in an ambulatory setting or does it require an inpatient admission?"
According 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 treatment of a medical status, are provided for the diagnosis, direct care, and handling of a medical condition, meet the standards of practiced medical practice in the local area, and aren't mainly for the convenience of the patient or doc."
An Introduction to Utilization Review
Healthcare has changed drastically in the last 100 years. Healthcare costs continue to rise, quality of care is questioned, and chronic diseases are axiomatic at present more than ever before. These challenges must exist addressed past the industry, and constructive solutions are a must.
Utilization review (UR) is 1 solution to the obstacles we face today in the healthcare industry. Utilization review is a method used to match the patient'southward clinical picture and intendance interventions to evidence-based criteria such every bit MCG intendance guidelines. This criteria helps to guide the utilization review nurse in determining the appropriate intendance setting for all levels of services across the arc of patient care.
History of Utilization Review
Due to rising costs after the consecration of health 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 allowed for reimbursement to the doctor for a reasonable and customary accuse. Due to ascent costs, and the offering 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 place waste. The utilization review function was initially performed by registered nurses (RNs) in the acute infirmary setting. The skillset gained popularity inside the health insurance industry, mainly due to growing research about medical necessity, misuse, and overutilization of services. Therefore, health plans began to review claims for medical necessity, and the infirmary length of stay (LOS). To contain costs, some health plans required the physician to certify the admission and whatever subsequent days afterward the access.
Utilization Review Procedure
There are iii activities within the utilization review process: prospective, concurrent and retrospective.
- Prospective review includes the review of medical necessity for the operation of services or scheduled procedures before admission.
- Concurrent reviews include a review of medical necessity decisions made while the patient is currently in an acute or postal service-astute setting.
- Retrospective reviews involve a review of coverage afterward 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, connected stay, level of care, potential delays in intendance and progression of care.
Medical necessity determines whether the infirmary admission is advisable, justifiable and reimbursable. Continued stay determines if each day of the stay is necessary and if the level of care is appropriate for that twenty-four hour period. Level of care determination identifies the near appropriate and needed level of intendance such every bit intensive or intermediate versus a medical-surgical flooring level of intendance. System delays are assessed and monitored to identify any potentially avoidable delays in intendance.
Progression of care, utilizing the guideline'southward Optimal Recovery Form, moves the patient through the continuum of intendance without delays and determines if services are appropriate, justifiable and reimbursable.
Applying the activities within the utilization review procedure, the nurse must accurately certificate the medical necessity and level of intendance based on evidenced-based criteria (such every bit MCG). The chart documentation must brandish the patient'southward electric current status, and why the condition cannot exist safely treated outpatient, and the risk associated if care is not provided at that level of care.
In conclusion, although this is an overview of the utilization review technique, it is important to annotation the process includes other methods such as doc second level review, CMS regulatory requirements, and in some cases clinical documentation improvement. Today, utilization review is 1 method used to demonstrate the quality of care and protect revenue integrity. Considering quality and costs are of paramount importance, utilization review nurses must possess clinical judgment and critical thinking skills to proactively mitigate overutilization and misuse of resources.
– Republic of india Watson, RN, MSN, BSN, CCM, CTT+ (June 21, 2018)
The information independent in this article concerns the MCG care guidelines in the specified edition and as of the date of publication, and may not reflect revisions made to the guidelines or any other developments in the subject thing after the publication appointment of the article.
Epitome courtesy Shutterstock/Monkey Business concern Images
References:
Daniels, S. & Hirsch, R. (2015). The Hospital Guide to Contemporary Utilization Review. HCPro.
Cesta, T. K., & Tahan, H. M. (2017). The case managers survival guide: Winning strategies in the new healthcare environment (Third ed.). Lancaster, PA: Destech Publications.
Centers for Medicare & Medicaid Services Glossary (2016, 0514) Retrieved from https://www.cms.gov/apps/glossary/default.asp?Letter=Thousand&Language=English language
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Source: https://www.mcg.com/blog/2018/06/21/utilization-review-medical-necessity/
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