Utilization Management

Learning Objectives Upon completion of this section the participant will be able to: Define Utilization Management. Understand the Utilization Management process in a hospital setting. Describe the types of Utilization Management reviews. Understand Quality Monitoring, Risk Monitoring, and Avoidable Days Monitoring.

Utilization Management (UM) is a process for assessing the delivery of healthcare services to determine if patient care is medically necessary, appropriate, efficient and meets quality standards. UM in a hospital setting includes the formal review of hospital inpatient or observation status patients on a prospective, concurrent, or retrospective basis. What is Utilization Management?

The UM process considers the following: How sick is the patient? What is the physician’s intent? What are we doing for the patient? What has been done in the outpatient setting? What is the discharge plan?

UM Benefits to the hospital: Cost Savings Decreased Length of Stay (LOS) Decreased denials Appropriate level of care Decreased health care costs

UM Benefits to the patient: Timely and efficient discharge. Patient safety: Increased risk of hospital acquired infections, skin breakdown, etc. with prolonged acute inpatient stays. The Institute of Medicine’s 2000 Report estimated that up to 98,000 hospital patients die each year due to medical errors.

Geographic Based: The case manager’s assignments are unit specific. Payer Based: The case manager’s assignments are based on the patient’s payer source, e.g. Medicare, Medicaid, Managed Care or uninsured. Physician Based: The case manager’s assignments are based on patients with the same attending MD or a hospitalist model. UM Assignments in an Acute Hospital Setting

Geographic Based UM Assignments Pros Builds working relationship with unit’s nursing, ancillary and clerical staff. Cons Decreased continuity with patient transfers to other units. May increase efficiency of the utilization management process Decreased customer service satisfaction with physicians dealing with multiple case managers. Efficient and effective discharge planning with usually one Case Manager.

Payer Based UM Assignments Pros Consistency in the review process for specific payers with the possible benefit of decreased denials. Cons The case manager may have patients in many different locations in the hospital. Relationship building with the payer reviewer. Relationships with nursing unit staff may be fragmented. Understanding of specifics of payer contracts. The payer reviewer may need to work with multiple Case Managers for discharge planning. Travel time to different hospital units.

Physician Based UM Assignments Pros Increased physician satisfaction from working with one case manager. Cons The case manager may have patients in many different locations in the hospital. Potential for more effective and efficient working relationship with physicians. Relationships with nursing unit staff may be fragmented. Clearer understanding of physician practice patterns. The payer reviewer may need to work with multiple Case Managers for discharge planning. Travel time to different hospital units.

The Use of Criteria in the Utilization Management Process Most UM in the hospital setting involves the use of written or computerized nationally recognized guidelines such as McKesson’s InterQual ® Criteria or Milliman Care Guidelines ®.

InterQual ® Criteria InterQual ® developed first set of criteria for managing the care of acute inpatient hospitalizations in InterQual ® Acute Criteria enables the case manager to determine if the care is clinically indicated and at the appropriate level of care. The use of InterQual ® Acute Criteria includes the selection of a criteria subset that most clearly identifies the patient’s most prominent presenting clinical findings.

InterQual ® Severity of Illness Criteria InterQual ® Level of Care Criteria includes Severity of Illness (SI) Criteria. SI criteria consist of clinical indicators of the patient’s illness and clinical presentation. SI criteria may include clinical findings, imaging results, EKG findings, and/or laboratory findings.

InterQual ® Intensity of Service Criteria InterQual ® Level of Care Criteria also includes Intensity of Service (IS) Criteria. IS Criteria consists of the actual patient care being delivered at a specific level of care. IS Criteria may include monitoring, specific IV medications, and other therapeutic services.

Milliman Care Guidelines ® Milliman Care Guidelines ® are evidence-based clinical guidelines including care pathways, quality measures, and integrated medical evidence that are used by case managers to make decisions about the care of patients.

Managed Care Guidelines/Criteria Managed Care Organizations (MCOs) may have developed their own specific criteria for different procedures and/or diagnoses. MCOs may opt not to use only one specific set of criteria or guidelines for approving inpatient stays.

Review Questions 1.What is one benefit to the hospital that utilization management provides? a)Increased cost of care b)Increased LOS c)Decreased denials 2.Name one nationally recognized utilization management criteria or guidelines: a)Center for Disease Control criteria b)InterQual ® Criteria c)Patient Outcome Guidelines

Answer Key 1.C 2.B

Utilization Management How to do a Review

Point of Entry Review Process Direct admission Surgical admission Emergency Department (ED) admission

Types of Reviews Precertification review – Occurs before an admission or surgical event. Apply the precertification criteria your facility uses.

Types of Reviews Examples of pre-certification reviews: Elective surgeries Planned direct admissions Facility-to-facility transfers

Types of Reviews Concurrent reviews: Admission concurrent review Continued stay concurrent review

Types of Reviews Admission concurrent review: Performed within 24 hours of admission. Continued stay concurrent review: Review completed within the time frame designated per your policy while the patient is still in your facility. Retrospective review: Occurs after discharge.

Direct Admission Review Review MD order sheet with admission diagnosis and interventions. Apply your criteria. Call MD for further information if needed. Check for correct level of care.

Elective Surgical Admission Review Check for preauthorization status. Check for number of days approved by MCO. Check for correct level of care. If unclear, call MCO.

Emergency Department Admission Review Review ED record and EMS trip sheet. Speak with ED MD and nurse caring for patient for further information if needed. Apply your criteria. Check for correct level of care.

Concurrent Admission Review Begin review with point of entry documentation Review medical record to include: MD orders Progress notes Lab results Graphic sheets Nurses’ notes Medication records Interdisciplinary team notes Apply specific criteria set

Concurrent Admission Review Ask yourself these questions: Does this patient meet criteria to be observation or inpatient? Is the patient at the right level of care? If all answers are YES – document your proof of criteria in your documentation system. Schedule next review per your policy guidelines.

Concurrent Admission Review If the answers to the questions were NO : Call attending MD for more information. (Insert your specific facility guidelines here)

Continued Stay Review Process Include a daily review for date of last review to present. Review medical record as previously stated.

Continued Stay Review Process Apply criteria Is patient still meeting criteria? If YES: Schedule next review in the future according to policy. If NO: Review interdisciplinary notes to assist in discharge plan. Call attending MD for further information.

Continued Stay Review Process Speak with your interdisciplinary team, patient and family regarding discharge plan. If the attending MD is not agreeable with discharge plan, insert your policy and procedure for addressing this matter. Assign avoidable days.

Continued Stay Review Process If the patient and/or family is not agreeable to the discharge plan, follow your institution guidelines for denial letter or Medicare appeal process if applicable. Document per your facility process guidelines.

Review Questions 1.True or False: For a continued stay review you should include a daily review for date of last review to present. 2. True or False: For an ED admission review you can include the EMS sheet as part of your review.

Answer Key 1.True 2.True

Condition Code 44 The CMS Manual, Chapter 1, Section 50.3, describes when and how a hospital may change a patient’s status from inpatient to outpatient, and further describes the appropriate use of Condition Code 44.

Condition Code 44 In some instances, a physician may order a beneficiary to be admitted to an inpatient bed, but upon reviewing the case later, the hospital’s utilization review committee determines that an inpatient level of care does not meet the hospital’s admission criteria.

Condition Code 44 (Cont’d) In cases where a hospital utilization review committee determines that an inpatient admission does not meet the hospital’s inpatient criteria, the hospital may change the patient’s status from inpatient to outpatient.

Condition Code 44 (Cont’d) To fall under this rule all of the following conditions must be met: The change in status from inpatient to outpatient is made prior to discharge. The hospital has not submitted a claim to Medicare. A physician concurs with the utilization review committee’s decision. The physician concurrence is documented in the medical record.

Condition Code 44 (Cont’d) (Insert your facility policy for Condition Code 44)

Other Types of Monitoring Quality monitoring Risk monitoring Avoidable day monitoring

Quality Monitoring “Quality monitoring are activities designed to monitor, prevent, and correct quality deficiencies.” POWELL’S (2000) Advanced Case Management Outcomes and beyond, Philadelphia: Lippincott Williams and Wilkens

Quality and Risk Monitoring While conducting a UM review, the Case Manager should be on the look out for patient care situations that are high risk or problem prone. The Case Manager should identify and report quality of care or risk issues to the appropriate department at your facility. Evaluate readmissions carefully for potential quality issues.

Quality Monitoring The Case Manager functions as the patient advocate, being proactive in addressing issues before they become problems. The Case Manager monitors quality indicators to identify potential problems early on in the hospital stay. The Case Manager should carefully assess readmissions.

Quality Monitoring (Insert your Quality policy.)

Review Questions 1.The Case Manager functions: a) Patient advocate b) Monitor quality indicators c) Being proactive in addressing issues d) All of the above

Answer Key 1. All of the above

Risk Monitoring “Risk Management is the process of making and carrying out decisions that will minimize the adverse effects of accidental losses. Risks and their prudent management are viewed as matters of patient safety.” CMSA Core Curriculum for Case Management 2001, Lippincott

Risk Monitoring The Case Manager will notify Risk Management when potential patient/family situations arise. The Case Manager notifies the Risk Manager as soon as an incident occurs. The Case Manager will notify Risk Management of any potential law suits.

Risk Monitoring (Insert your Risk Management plan.)

Review Questions 1.True or False: Risks and their prudent management are viewed as matters of patient safety. 2.True or False: Case Management should be on the lookout for situations that are low risk and happen infrequently.

Answer Key 1.True 2.False

Avoidable Days Identifying and Recording Avoidable Days

Overview Case Management is key in identifying delays in patient treatment and hospital days as well as concerns relating to patients during their hospital stay.

Definition of an Avoidable Day An occurrence or event during patient’s hospital stay that causes an increase in the patient’s length of stay or a delay in discharge.

Avoidable Day Types Physician Delays Hospital or Department Delays Continuum/Discharge Delays

Avoidable Day Reporting (Insert your avoidable day reporting process.)

Physician Avoidable Days Definition: A delay in care related to Physician performance. Example: Patient is not meeting acute care criteria and no discharge order written.

Hospital/Department Avoidable Days Definition: A delay in care related to a hospital breakdown in process. Example: Physician orders a heart catheterization, but it is not performed for 2 days due to Cath Lab scheduling.

Continuum/Discharge Avoidable Days Definition: A delay in care not related to the physician or hospital, yet by an outside resource or provider. Example: Patient has order to be discharged to Skilled Nursing Facility and there are no beds available.

Avoidable Day Reporting Avoidable Day Reports are a useful tool for the management team and the organization.

Avoidable Day Reporting Avoidable day tracking provides us with the ability to build and generate standardized reports. Avoidable day tracking gives us the opportunity to identify trends.

Avoidable Day Reports (Cont’d) (Insert examples of your avoidable day types and reasons)

Positive Outcomes from Avoidable Day Reports Through the tracking and trending of delays by type and reason we have been able to: Work with physicians to provide education as needed. Identify areas for improvement. Open communication with outside providers.

Positive Outcomes from Avoidable Day Reports (Cont’d) Through the tracking and trending of delays by type and reason you will be able to: (Insert your outcomes)

Review Questions 1.True or False: An avoidable day is an occurrence or event during a patient’s hospital stay that causes an increase in the patient’s length of stay or delay in discharge. 2.True or False: A physician delay is a delay in care related to physician performance.

Answer Key 1.True 2.True

References CMSA Standards of Practice for Case Management (2002), Little Rock, AR CMSA Leaders Guide to Hospital Case Management (1998) Steffani/Ramey Interqual ® Level of Care – McKesson Health Solutions 2007 Milliman ® Care Guidelines