The Hospital Guide to Contemporary Utilization Review is a comprehensive resource designed to identify utilization review (UR) best practices and provide guidance on developing and enhancing a contemporary UR committee. This book focuses on the latest UR and patient status requirements to help hospitals perform high-quality reviews and comply with regulations.

The book covers a range of topics, including compliance with the UR Condition of Participation, legal obligations of a hospital, contract language, and compliant UR plan language to provide an understanding of the expectations of a UR program. Tips for intradepartmental collaboration are included to guide professionals through the process of selecting a physician advisor and partnering with nurses, case managers, and revenue cycle team members.

This book will help you do the following:

• Identify the components of a best practice hospital utilization review (UR) program
• Describe the legal obligations of the hospital to comply with chapter 42 CFR 482.30 of the Conditions of Participation (CoP)
• Use the publication as a tool to assess his or her own hospital's UR processes
• Summarize the benefits of a dedicated UR team to promote compliance with the CoP
• Facilitate the development of a contemporary UR committee
• Assess an organization's opportunities to improve processes to benefit patient care and hospital success
• Recommend compliant language for the organization's UR plan
• Construct commercial contract language, in collaboration with the organization's contract manager, that promotes a partnership to ensure appropriate use of acute care resources
• Seek out operational resources to perform high-quality reviews that fully comply with the CoP
• Explain the connection between a good utilization review plan and the hospital revenue cycle initiatives

Chapter 1: History of Utilization Review

• Learning Objectives
• Introduction
• Terminology: Is It Utilization Review or Utilization Management?
• History of Utilization Review

• Learning Objectives
• Healthcare Regulations
• Conditions of Participation
• Insurance Contracts
• The Regulatory Alphabet

• Learning Objectives
• Background Information
• Committee Membership
• Reporting Structure
• Utilization Review Plan Content
• The Utilization Review Committee Agenda
• Data Support

• Learning Objectives
• The Utilization Review Team
• The Utilization Review Specialist
• First-Level Reviewers
• Virtual Utilization Review
• Second-Level Reviewers
• The Physician Advisor
• Outsourced Resources
• Staffing
• Case Managers
• Residents, Hospitalists, and Private Attending Physicians
• The Revenue Cycle Team

• Learning Objectives
• Defining Medical Necessity
• Prospective Reviews for Elective Admissions
• Pre-Certification for Elective Services
• Medicare Inpatient-Only List
• Elective Medical Admissions
• Concurrent Reviews for Emergent Conditions
• The 2-Midnight Rule
• Practical Application of the 2-Midnight Rule
• Practical Application Using Screening Tools
• Other Practical Applications of the 2-Midnight Rule
• Exceptions to the 2-Midnight Rule
• Applying the 2-Midnight Rule to Transfer Patients
• Medical Documentation and the Utilization Review Process
• About Observation Services
• Continued-Stay Review
• Continued-Stay Review for Treatment of Primary Disease
• Continued-Stay Review for Additional Testing
• Determination of Proper Status
• Level of Care Within the Hospital
• Secondary Review

• Learning Objectives
• Resources for Utilization Review Specialists
• Training and Education
• Nationally Recognized Acute Care Criteria
• Best Practice Protocols
• Regulatory Updates
• OIG Work Plan
• Commercial Contract Information
• National and Local Coverage Determinations
• Surgical and Nonsurgical Invasive Criteria

• Learning Objectives
• Effective Progression of Care
• Objective Outcomes
• Supplier Information
• Physician-Specific Practice Profiles
• Physician-Specific Denial Information
• Progression-of-Care Delays and Avoidable Days
• Discharge Planning and the Utilization Review Function
• Utilization Review Documentation

• Learning Objectives
• Ethical and Legal Obligations for Utilization Review
• Principles of Medical Ethics
• Legal Considerations
• Regulatory Issues Relevant to the Utilization Review Specialist
• Advance Beneficiary Notice
• Hospital Issued Notices of Non-Coverage
• Certification of Admissions
• Condition Code 44
• Self-Denial of Inpatient Admissions

• Case managers
• UR coordinators
• UR committee members
• UR physician advisors
• Nurse managers
• Revenue cycle managers
• Compliance officers and auditors
• Healthcare lawyers and consultants