Utilization Management

Utilization management (UM), which is the appropriate use of health care services, in the correct setting, done in a timely manner, can be leveraged to provide evidence-based care to patients while also meeting the regulatory and contractual responsibilities to payers

An increase in the hospital observation rate is affecting many adult and pediatric facilities. This is a national trend that has significant impact on hospital reimbursement. In this environment, it’s important for hospitals to have an effective utilization management (UM) program that evaluates the medical necessity of admissions in a timely manner, ensures the patient is placed in the appropriate status (inpatient, outpatient, observation services), interfaces with payers throughout the stay with peer-to-peer contact, and also provides for a strong written appeals program if a formal denial is received. Our physician UM leaders can work with your UM team on systems (i.e. InterQual™ or MCG (Milliman™)) and processes that can create a streamlined and effective UM program to ensure your hospital is optimizing its processes and progressing towards best practice in status determination.

Potential areas for assessment and intervention

  • Optimize concurrent and retrospective review processes
    • Onsite observations & interviews
    • Chart audit of observation cases
      • InterQual™ or MCG™ status determination to evaluate UM nurses use of the tool
      • Documentation opportunities that could have supported a different status
  • Appropriate status/UR at admission points or within 24 hours
  • Optimize use of InterQual™ and MCG™ guidelines by UR nurses
  • Timely order for status from the physicians
  • Escalation to secondary or tertiary review
  • Peer-to-peer education for physicians and physician advisors
  • Daily review of observation cases and short inpatient cases
  • If formal denial received:
    • Screening for appealability
    • Written appeal process & secondary appeal process
    • Tracking of outcomes & reviewing trends
  • State Medicaid, managed care, and commercial observation guidelines & reimbursement models
  • Inpatient, observation, and outpatient in a bed metrics
  • UM committee charter, composition, and process
    • Key metrics to trend with appropriate peer comparison (i.e. PHIS, etc…)
  • Internal Physician Advisor program development and onboarding