UM in the US[17757].ppt

Utilization Management
in
the U.S

Objectives
• At the end of module, the learner will be able to
• Identify what is Utilization review/management
• Entities of Utilization review
• Important of Utilization review
• Unitization review process and screening tools

Utilization Management Defined
• The evaluation & management of medical necessity,
appropriateness, and efficiency of medical services and
procedures

Entities in Utilization Management

Organizations
• Health care facility
• Government/Commercial payor
• Government entity who regulate the rules
• Medicare
• Medicid

Utilization Review department
• Health care facility
• Insurance

Example of Utilization Department in the
hospital
• Director
• Administrative Assistant
• Patient account representatives or PARs
• Physician Advisors
• Payor Team Managers
• Team Specialists
• Utilization Mgmt. RNs
• Denial UM

Utilization Manager RN
 collaborate with the business office to ensure notice of admission (NOA) &
accurate payor information has been received
 prepare extracted information from the patients medical record in the
form of a “clinical” summary & applies appropriate InterQual® criteria set
to each OBS/INPT admission
 assure the admission order accurately relates to the appropriate level of
care indicated & the order is signed/co-signed by MD
 validate payor authorization matches the physician order and level of care
being provided

• ensuring proper status
• encouraging accurate documentation of the patient’s medical status
• documentation of D/C disposition
• delivery of HINNS (hospital issued notice of non-coverage)
• delivery of ABN’s (advance beneficiary notice)

• Collaborates with Clinical CM, SW & MD to expedite D/C plan when it
becomes appropriate
• Collaborates with MD to clarify severity of illness and treatment plan
if it is unclear
• Facilitates peer to peer communication with payer’s medical director
to defend case as needed

Why is RN experience essential to Utilization
Management?
• Because a seasoned RN:
• Is a patient advocate
• Is a credible member of the healthcare profession
• Is proficient at reviewing medical records
• Is capable of ‘reading between the lines’
• Is skilled at noticing the immediate needs of a patient
• Is experienced in regards to abnormal findings
• Is able to identify errors / omissions & can seek clarification
• Is familiar with the standard of care for a particular condition
• Is able to recognize discrepancies (medication, test report etc.)

Denials Management
12
UM Team Denials Team
Handles denials issued for incomplete or lack of
clinicals
Handles other situations where clinicals did not
reach the payor on time
UM Specialist will initially review the denial to
determine why case was denied and assign the case
to the appropriate UM staff member
Handles appeals for denials issued >1 week post D/C
Handles denials due to changes in payor not known until >1
week post D/C
Manage retrospective submissions for Medicaid cases
Conducts case audits to identify learning/coaching needs
Suggests alternate presentation of denied cases for
improvement
New staff receives specialized training in Denials
Management

Types of Payors in the US
• Commercial
• Government

Commercial Payors
Per Diem method of payment
• Set dollar rate per-day has been negotiated LHS
• Clinical summaries must support
• daily severity of illness
• daily intensity of service

Commercial Payors
DRG (diagnosis related grouping)
• Follow Medicare guidelines for LOS & rates
• Negotiates with LHS to pay a % of the Medicare DRG rate
• Show initial severity of illness & intensity of service
• Payor will request additional reviews if > anticipated LOS

Government Payors
• Medicare Part A (pays Hospital inpatient stays)
• Medicare Part B (outpatient services, including MD visits)
• clinical summaries are saved in system, not faxed anywhere
• Part C: Managed MCR plans
• Examples: AARP, Wellmed, UHC
• treat like Commercial Payor
• fax clinical summary

Government Payors
• Traditional Medicaid
• Clinical submitted online to eQHealth
• Medicaid HMO
• treat like Commercial Payor
• fax clinical summary

Medical necessity screening
for Utilization review

Patients Entry point to the hospital
• Via Emergency Department
• After an initial evaluation & treatment → if pt. requires further workup and treatment for a diagnosed
or undiagnosed condition
• As Direct admit
• Acute
• Sent from office by MD (OB, PEDS), urgent care, transfer from another facility (sister hospital, SNF, ALF, etc.)
• Elective
• Surgical- should always come in the day of surgery, not before
• Appropriate early admit --> intractable pain, anticoagulant reversal, post cardiac catheterization & requires
surgery within 24h
• Cardiac/pulmonary clearance should already be on file
• Prescheduled procedures should have prior auth on file

Status of patients in the hospital
• Extended recovery
• Observation
• Inpatient

Examples of Observation Status
Acute Coronary Syndrome (ACS, rule out MI)
Altered Mental Status (with or without existing dementia)
Issues following outpatient surgery or procedure
Pain: abdominal; intractable back or chronic back
Rule out…
Shortness of breath (if hypoxic, usually meets Inpatient)
Syncope / Pre-syncope /TIA
Vomiting
Asthma
Bleeding and hemodynamically stable
Chest pain
Dehydration
Diarrhea
Gastritis

Observation after OP surgery
• For post surgical patients that are hemodynamically stable, but require 6-24h of
treatment or assessment pending a decision regarding the need for additional
care
• Examples:
• any delayed recovery from anesthesia
monitoring level of consciousness, persistent hypotension
• laparoscopic appendectomy with uncontrolled pain
monitoring pain level, change in pain medication

Extended recovery status
• Hemodynamically stable patients with an OBS admit order, who require
additional time but do not have observation criteria
 did not have unexpected events/treatments
 billing office is notified to avoid bed charges
 Message is placed in the billing section in EPIC (STOP BILL)
 triggers B/O to review account & remove bed charge before billing the payor
• Examples:
• Amputation of finger
• Uncomplicated, transferred to floor until discharged
• ORIF patella fracture
• Uncomplicated, transferred to floor (for PT evaluation & further monitoring) until discharged

Observation
 hemodynamically stable patients that require 6-24h of treatment or
assessment pending a decision regarding the need for additional care
 a ‘second level review’ process is utilized to ensure compliance and
appropriateness for “OBS”
 “OBS” is Billed under Medicare Part B as outpatient or individual
commercial/Medicaid payor rules
 if order is originally for INPATIENT and needs to be changed to
OBSERVATION – this is called a Medicare Condition Code 44

INPATIENT STATUS
• Hemodynamically stable patients who require treatment, assessment or
intervention every 4-8h or every 1-2h if in critical condition
• Examples:
• Pneumonia
• Acute Myocardial Infarction
• Pancreatitis
• Diabetic Ketoacidosis
• Cardiac arrest

Medical Necessity Screening tools
• Interqual,
• Milliman, or
• other proprietary systems
• Example Xolis using AI system
Chapter 8 Medicare guideline for SNF

Clinical information should include
• Findings / Severity of illness
• Interventions / Intensity of service
• Discharge plan

• Consists of criteria justifying an admission for eval, care and treatment of an acute condition.
• Supporting documentation may include:
• failed outpatient Tx, include ED – what was provided & didn’t work?
• complexity of signs and symptoms
• evidence of instability or high risk for complications or mortality
• advanced age / multiple co- morbidities
• treatment plan & tentative D/C plan if known

• UM RN will review the patient's record, possibly prospectively in the ED
• usually during the first 24 hours of admission, to determine if the screening tool's criteria are
met. The main criteria relate to
• intensity of service (IS)
• severity of illness.( SI)

intensity of service (IS)
severity of illness.( SI)
• . Both SI and IS criteria must be met to support the medical necessity for admission ( inpatient ,
observation
• Many of the criteria are similar for observation and inpatient but the inpatient admission SI and
IS criteria indicate higher acuity.

Important of patient’s status
• The observation vs. inpatient admission decision is an important because can result in
• payment errors
• compliance concerns
• carries the risk of payment denial
• lost revenue for the hospital.

Healthcare Costs without Medical Necessity
© Copyright 2017 McKesson Corporation and/or one of its
subsidiaries. All rights reserved. Produced in Cork, Ireland.
32
34%
66% 1 day stay
All other
medical
necessity
denials
66%of
medical necessity
denials were for
medically
necessary care
provided in the
wrong setting,
costing hospitals
$257 million
AHA. (April 2014). RACTRAC Survey; Unnecessary Imaging, 2014, peer60 data; Epstein NE. Are recommended spine operations either unnecessary or too complex? Evidence from second opinions. Surg Neurol Int
2013;4:S353-8; US Department of Health & Human Services. Supplementary Appendices for the Medicare Fee-For-Service 2015 Improper Payments Report.
~60% of patients
referred for
cervical or lumbar spine surgery
were told that they needed
unnecessarysurgery
Unnecessary imaging tests
may account for up to
$12B annually
40%
of DME
payments
were
improper
85%
attributed to
insufficiently
supported
medical
necessity
Totaling
$3.2
billion

Criteria of the tools
• are organized by body system:
• general,
• cardio/respiratory
• CNS,
• GI
• metabolic
• obstetrics,
• surgery/trauma.

Intensity of Service ( IS)
• assessments
• Monitoring
• medications
• blood products
• IV fluids
• psych crisis intervention. Both SI and IS criteria must be
met to support the medical necessity for admission,
observation or another service in the system. Many of the
criteria are similar for observation and inpatient but the
inpatient admission SI and IS criteria indicate higher acuity.
Examples below.

Sample
InterQual®
application:
35

InterQual Evidence-Based Development
36
1. InterQual Clinical Development
Team identifies content for
development and updating
2. Clinical Development Team critically
appraises the clinical evidence
3. Clinical Development Team
develops draft content
4. Independent clinical review panel,
drawn from 850+ experts, provides
authoritative peer review and
validation
5. Clinical Development Team
conducts final quality assurance
check and releases content

37
Sample Review
Blank review template: All filled in:

“A level of care determination tool, intended to be used as real-
time decision support in the emergency department”
“Helps to determine whether a patient is appropriate
for OBS or INPT admission”
Initial review or screen

Initial review
Notice there are NO
ongoing interventions or
full set of treatment /
medication orders

Initial review VS Episode Day 1
• While Initial review enables identification of the level of care, it is not
intended to, and should not be used as, a substitute for an Episode Day 1
review, which will generally include specific, evidence-based interventions
and intensity of service requirements
• We would conduct an Episode Day 1 review (and not an Initial review)
under the following circumstances:
• After the decision to admit has been made
• If you’re conducting the review retrospectively
• If you have a full set of treatment or medication orders
• If you have sufficient information to conduct an Episode Day 1 review

46
Recommend
OBSERVATION
status

48
• Stuart, a 79-year-old male, was brought to the ED by his
family. They report Stuart seemed confused this
morning and was slurring his words. He was unable to
stand, even with assistance; the left side of his mouth
was drooping. Stuart had surgery 2 weeks ago for a
bowel obstruction. He has been recovering at his
daughter's home without complications until this
morning. Stuart has a past medical history of
hypertension, atrial fib, MI x2, COPD and smoking.
• He has been on warfarin PO at home; however, levels at
this time are sub-therapeutic. Stuart is evaluated 6
hours after the initial onset of symptoms. His condition
is not amenable to endovascular intervention.
Case Study 1A

49
Case Study 1A
• (continued)
• Physical Examination/Clinical Findings
• Pale, elderly man who is confused
and has difficulty forming words
• BP 167/102 mmHg, P 122, Resp 24, T
98.9° F (PO), O2 saturation 91% on
room air
• INR 1.1
• Lungs clear to auscultation
bilaterally, CXR WNL
• Blood glucose 117 mg/dL
• Abdominal incision healing, well-
approximated, without drainage
• Left-sided weakness; muscle strength
2/5
• ECG shows atrial fibrillation
• CT of the brain reveals focal ischemia, no evidence
of a hemorrhage or mass

50
Case Study 1A
• (continued)
• Medical Practitioner’s Orders
• Admit, diagnosis: Ischemic stroke (non-
hemorrhagic), atrial fibrillation
• Vital signs q4h with oximetry and neuro
assessment
• O2 at 2L/min nc
• Telemetry
• PT/INR, CBC, Metabolic panel in am
• Heparin drip per protocol
• Daily INR, contact MD with results
• Diltiazem 20 mg IV bid
• NPO until swallowing assessment
• Bilateral pneumatic compression devices for the
lower extremities

Case Study 1A
51
Criteria subset Stroke
Initial review or episode day Episode Day 1
Level of care Acute
Criteria met? Yes
Responder criteria N/A
Review outcome Approved
Reviewer action Approve and schedule the next review

52
• Episode Day 4
• Stuart was admitted 4 days ago and was diagnosed with
an ischemic stroke.
• Stuart underwent a swallowing assessment and is able
to tolerate soft foods and nectar-thick liquids. He is
confused and his speech remains slurred. He is
incontinent of stool; he has a condom catheter. Stuart is
experiencing controlled atrial fibrillation. Anticoagulant
therapy continues. Stuart is febrile, has a productive
cough with thick yellow sputum, and his chest x-ray
reveals pulmonary infiltrates; he has been diagnosed
with pneumonia. Stuart underwent evaluations in
physical therapy, occupational therapy, and SLP.
• Physical Examination/Clinical Findings
• Vital signs: BP 138/72 mmHg, P 89, Resp 24, T
100.2° PO, oxygen saturation 92% on 2L/min nc
(baseline is 93%)
• Inspiratory and expiratory wheezing, crackles
auscultated bilaterally, lung sounds diminished
• CXR reveals bi-basilar pulmonary infiltrates
consistent with pneumonia
Case Study 1B

53
Case Study 1B
• (continued)
• Medical Practitioner’s Orders
• Vital signs q4h with oximetry and neuro
assessment
• O2 at 2L/min nc to keep oxygen saturation > 95%
• Continue telemetry
• INR daily
• Warfarin PO per daily MD order
• Nebulizer treatments q4h, respiratory protocol
• Sputum for culture and sensitivity
• Cefotaxime 2 g IV q4h
• Diltiazem ER 180 mg PO bid
• Soft diet with nectar-thick liquids
• Continue PT, OT, and SLP daily as tolerated
• Continue use of pneumatic compression devices
for the lower extremities

Case Study 1B
54
Criteria subset Stroke
Initial review or episode day Episode Day 4
Level of care Acute
Criteria met? Yes
Responder criteria Partial responder

Case Study 1C
55
• Today is Episode Day 7. INR within therapeutic range. Temp 100.0° F PO. Anti-
infectives transitioned to PO yesterday evening. Nebulizer treatments
continue. WBC 14,000/cu.mm. CXR ordered. O2 sat 94% on 2L/min/nc of
oxygen. Stuart is tolerating soft foods and nectar-thick liquids.

Case Study 1C
56
Criteria subset Stroke → Extended Stay
Initial review or episode day N/A
Level of care Acute
Criteria met? Yes
Responder criteria Partial responder

References
• Reyes, Ireda, (2018) Utilization Review Training Manaul
• McKesson Corporation (2020) I InterQual Level of Care Acute Criteria Adult

UM in the US[17757].ppt

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