Implement Claims Decision Tools for Utilization Review Nurse
The Scenario: A patient named Sam entered the Emergency Section (ED) with intestinal hurting. He was triaged and escorted to a handling room. After an assessment, examination, lab tests and imaging, information technology was determined Sam had appendicitis. He was scheduled for surgery the side by side morning for an appendectomy. Susan, the utilization review nurse, analyzed Sam'south electronic medical record the next morning. Susan asked herself, "Is the surgery medically necessary?" and "Can 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 every bit "services or supplies that: are proper and needed for the diagnosis or handling of a medical condition, are provided for the diagnosis, direct care, and treatment of a medical status, meet the standards of expert medical practice in the local surface area, and aren't mainly for the convenience of the patient or medico."
An Introduction to Utilization Review
Healthcare has changed drastically in the last 100 years. Healthcare costs continue to ascension, quality of intendance is questioned, and chronic diseases are axiomatic now more than ever before. These challenges must be addressed by the industry, and effective solutions are a must.
Utilization review (UR) is one solution to the obstacles we face today in the healthcare industry. Utilization review is a method used to match the patient's clinical picture and care interventions to evidence-based criteria such as MCG care 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 health insurance in the 1960s, President Lyndon B. Johnson and the U.S. Congress responded with programs we now call Medicare and Medicaid. Medicare/Medicaid allowed for reimbursement to the physician for a reasonable and customary charge. Due to rising costs, and the offering of healthcare insurance from employers to employees, utilization review was presented.
Utilization review, equally a process, was introduced in the 1960s to reduce overutilization of resources and identify waste product. The utilization review function was initially performed past registered nurses (RNs) in the acute hospital setting. The skillset gained popularity inside the health insurance manufacture, mainly due to growing enquiry most medical necessity, misuse, and overutilization of services. Therefore, health plans began to review claims for medical necessity, and the hospital length of stay (LOS). To contain costs, some health plans required the physician to certify the access and any subsequent days after the admission.
Utilization Review Process
There are three activities within the utilization review process: prospective, concurrent and retrospective.
- Prospective review includes the review of medical necessity for the performance of services or scheduled procedures before admission.
- Concurrent reviews include a review of medical necessity decisions made while the patient is currently in an astute or post-acute setting.
- Retrospective reviews involve a review of coverage after treatment is provided.
The consummate utilization review process consists of precertification, connected stay review, and transition of care.
When a patient is admitted to the facility, a commencement level review is conducted for appropriateness; this includes medical necessity, connected stay, level of care, potential delays in care and progression of care.
Medical necessity determines whether the hospital 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 24-hour interval. Level of care determination identifies the most appropriate and needed level of care such as intensive or intermediate versus a medical-surgical floor level of care. System delays are assessed and monitored to place any potentially avoidable delays in care.
Progression of care, utilizing the guideline's Optimal Recovery Form, moves the patient through the continuum of care without delays and determines if services are advisable, justifiable and reimbursable.
Applying the activities within the utilization review procedure, the nurse must accurately certificate the medical necessity and level of care based on evidenced-based criteria (such as MCG). The chart documentation must display the patient's current condition, and why the condition cannot be safely treated outpatient, and the hazard associated if intendance is not provided at that level of care.
In conclusion, although this is an overview of the utilization review technique, it is important to note the process includes other methods such equally dr. second level review, CMS regulatory requirements, and in some cases clinical documentation improvement. Today, utilization review is i 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 critical 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 commodity 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 area thing afterward the publication date of the article.
Image courtesy Shutterstock/Monkey Business Images
References:
Daniels, S. & Hirsch, R. (2015). The Hospital Guide to Gimmicky Utilization Review. HCPro.
Cesta, T. G., & Tahan, H. M. (2017). The example 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=Thou&Language=English
If you are an MCG customer, log into the MCG Community to hash out this blog with other members. If yous're not still a member of our Community, sign upwards here.
Source: https://www.mcg.com/blog/2018/06/21/utilization-review-medical-necessity/
0 Response to "Implement Claims Decision Tools for Utilization Review Nurse"
Postar um comentário