Utilization Review Boot Camp – May 14, 2014
UR Committee and Round Table Session Notes
Cabinet Peaks Medical Center – Libby, MT
CPMC coversCOPs for hospitals in their UR Plan as CAH COPs are silent. Meet quarterly and have physician advisors on the UR Committee. CPMC has 7 day/week UR staff to review every case admitted. They use the InterQual Care Enhancement Program. UR staff reviews case, insert parameters and program gives green/red light for medical necessity or not for that level of care. If a case does not meet medical necessity then it is discussed with hospitalist or attending doc. If there is a disagreement then the case is given to UR physician for review and case is discussed physician to physician.
Huddles every morning with hospitalist and UR staff, typicallyRT, PT and nurses are there also. A census is run every morning with needed information. If a patient is in for 6-7 day they do a case conference to determine what more can be done, why they are still in their status.
Big Horn County Hospital – Hardin, MT
Cheryl at Big Horn does both PI and UR. UR was previously done by biz office with no consistent process. Cheryl started from scratch with a list of contact numbers, a process of reviewing charts. There is no committee that meets and Cheryl does inpatient, outpatient and swing bed for appropriate use of admission. Works with the ADON who supervises swing bed on those cases. Big Horn usesMilliman for guidelines.
Barrier that UR not available 24/7 and keeping up with cases can be difficult as they come in waves. It takes a lot of disciplined work to keep up.
Northern Montana Healthcare – Havre, MT
Developed a spreadsheet to do as a report on a daily basis. Fields include: Date, patient name, medical record/visit number, physician, diagnosis, case manager, Status (Obs/Inpt), Interqual/Milliman Guidelines, medical necessity or not, level of stay (1 midnight, 0 midnight), readmission, transferred, comments.
Roosevelt Medical Center – Culbertson, MT
UR committee meets when they get inpatient or skilled swing bed and complete form to determine medical necessity. Struggling with writing a policy as they can’t make COP fit with the ability of the facility. They do not have 2 physicians so there are struggles with the small numbers of providers able to consult without involving the physician that is in direct involvement of the patient’s care. Although no one on the call reported having a policy in place to address this, it was advised to just establish that “go-to” person at the hospital.
Northeast Montana Health Systems – Wolf Point & Poplar, MT
NEMHS has a committee that meets monthly or every other month. The review of the chart is scattered, someone in medical records reviews every chart and if there are problems will approach nurse reviewers. No policies or procedures.
Marcus Daly Memorial Healthcare – Hamilton, MT
Meet 7 days a week with different disciplines (nursing dietary, OT, PT, Pharm, etc) look at individual patient and goals and medical necessity. One UR nurse that initiates authorization and concurrent reviews for all private insurance companies and Medicare ACOs. Medical review UR committee meets quarterly and talks about HINSS, processes, readmits, claims denials.
Liberty Medical Center – Chester, MT
Committee meets weekly with DON, social services, medical records and billing. They cycle in a provider once a monthand give projects like checking on level of care appropriateness. Very, very low utilization.Reported to Medical Staff monthly and providers are given copies of minutes.
Holy Rosary Healthcare – Miles City, MT
UR Committee meets every other month. UM plan and case managers that doInterQual reviews on daily basis and continued stays with those every 2-3 days. Night supervisor runs reviews to get correct status before midnight. Daily huddles are done to try to stay on top of things.
Glendive Medical Center – Glendive, MT
What do facilities do for UR Nurse training? Most just turn it over or have outgoing staff train.
Training resources:
- Qualis Healthcare – InterQual system – Medicaid utilizes them.
- McKesson can certify, credits every two years. CPUR “Health Management” or “Certified Professional Healthcare Management”
Community Hospital of Anaconda – Anaconda, MT
UR meets weekdays at 9am. Have policies but have a problem with determining a physician champion who is willing to oversee UR when another physician thinks patient needs to be admitted and no longer meets criteria.
Central Montana Medical Center – Lewistown, MT
Same physician champion issue as others. CMMC has a UR committee that is chaired by a physician. This works okay at committee meetings but find difficulty getting assistance on day to day issues. RAC is subcommittee of the UR Committee. Meet weekdays on all patients.
Providence Kodiak Island Medical Center– Kodiak, AK
Providence Kodiak has physician champion challenges as well and they contract with Executive Health Resources (physician advisory company) since they do not have a UR physician. Kodiak contacts them when an inpatient isn’t meeting InterQual criteria or an observation patient that can possibly go to inpatient but no physician buy-in. Their contract is $249 to call in, initial case and all calls after that.
Clark Fork Valley Hospital – Plains, MT
UR meets on weekdays with good process, but no access to criteria resource. CFVH inquired as to InterQual costs.
- InterQual – contract for written books – resources gives direction to observation/admission. $8000/year. Online content is more. This from a facility that doesn’t have EHR yet. They would like UR to go online with their EMR and that time will go to online InterQual.
- Cabinet Peaks Medical Center uses InterQual Care Enhance, which is an interactive program. Includes swing bed, surgical indicator and medical necessity and online book and paper book. $15,000/year at three year price lock. 29% discount for CAHs
Providence St. Joseph Medical Center – Polson, MT
We hold a daily interdisiplinary rounding meeting to discuss each patient's status and care -we've found this leads to improved patient care, fewer re-admissions, and fewer surprises on discharge.
We have a UR/denials committee that is supposed to meet every 2 months.
The below mentioned documents will be posted on the CAH Facility Forms section of the PIN Website and the UR Boot Camp page.
Insurance Worksheet: I record all of my conversations, faxes etc. on this and attach any letters I receive - this goes in my file to help answer questions later.
Code 44 documentation: We use this to document that we have covered all of the steps called for in the MCR COP so that we can turn around and bill with the Code 44. Our MD pool is so small that effectively every physician in the hospital is a UR physician. If I need a signature (thankfully not very often) I first discuss it with the admitting MD and then go talk with the first 2 MDs that I can find in house to get the other 2 needed signatures. This gets scanned into the patient Medical Record and is proof that we followed COP. This is also a signal to the coders and billing staff that the Code 44 is OK to use.
Utilization Management notes: I used this form to record my certification of a patient's status for the Medical Record before we were on EPIC (we used Meditech then). Now I make a UR note in the Case Management section.
Patient Review Worksheet: This was my worksheet for reviewing patients before we were on EPIC and I had to read multiple charts each morning. It allowed me to organize all of the pertinent details for the patients so that I could review them back at my desk later. We used Interqual (book) at that time; we use Milliman software now so reviewing patient info is all done from the same computer screen.
Question to case managers: How do you get started on discharge planning when docs aren’t wanting to start?
Start at the bed side long before the physician thinks about discharge. Take charge of the discharge process and begin determine resources at home, etc. This can be documented in EHR case management/social work flow sheet or even in a normal nursing progress note.