CMI: Centers for Medicare and Medicaid Services — Conditions of Participation for Utilization Review
March 1, 2014
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Centers for Medicare and Medicaid Services — Conditions of Participation for Utilization Review
By Toni Cesta, PhD, RN, FAAN
Introduction — The Utilization Review Process
As we have discussed in prior months, hospitals that are participating in the Medicare and Medicaid programs — meaning that they receive reimbursement from Medicare and/or Medicaid — are required to participate in Medicare's "Conditions of Participation" (CoP). The CoP includes the actions that hospitals are required to perform in order to continue to participate in the Medicare and Medicaid programs. They are required and not optional.
As discussed, case managers are bound to two of the components of the CoP. These are the discharge planning sections and the utilization review sections. This month, we will review the CoP for utilization review.
The First Role of Case Managers
Utilization review was the first role assumed by hospital case managers. It was a stand-alone role and was performed as a requirement under the Medicare program. As the case management models evolved, utilization review was subsumed as one of many roles performed by hospital case managers. Whether your case management model applies utilization review as a stand-alone role, or whether it is part of an integrated approach, your hospital is bound by the components of the CoP for utilization review. Therefore, it is critical that you are aware of what these requirements are and that they are also included in the hospital's utilization review plan.
Section 482.30 Issued and Effective on 10/17/08
The section on utilization review starts with the basic requirement of the section. It states the following:
"The hospital must have in effect a utilization review (UR) plan that provides for review of services furnished by the institution and by members of the medical staff to patients entitled to benefits under the Medicare and Medicaid programs."
The hospital's utilization review plan should include the following:
- a delineation of the responsibilities and authority for those involved in the performance of UR activities;
- procedures for the review of the medical necessity of admissions;
- the appropriateness of the setting;
- the medical necessity of extended stays; and
- the medical necessity of professional services.
The Utilization Review Committee
The utilization review committee must include two or more practitioners who carry out the utilization review functions. At least two members of the committee must be doctors of medicine or osteopathy. The other members can be any type of practitioner.
The UR committee must be one of the following:
- a staff committee of the institution that has delegated to the UR committee the authority and responsibility to carry out the UR functions
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a group outside the institution
- established by the local medical society and some or all of the hospitals in the locality; or
- established in a manner as approved by CMS (The Centers for Medicare & Medicaid Services).
If your hospital is too small to practically have a functioning UR committee, then a committee must be established as per above.
The committee's reviews cannot be conducted by any individuals who have any of the following:
- a direct financial interest in the hospital (an example would be an ownership interest) or
- were professionally involved in the care of the patient whose case is being reviewed.
Section 482.30(c) Standard: Scope and Frequency of Review
This section discusses the manner in which clinical reviews must be conducted. This information must be included in the utilization review plan as well.
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The UR plan must provide for review for Medicare and Medicaid patients with respect to the medical necessity of:
- admissions to the institution
- direction of stays, and
- professional services furnished including drugs and biologicals.
- Review of admissions may be performed before, at, or after admission to the hospital.
- Reviews may be conducted on a sample basis.
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Hospitals that are paid for inpatient hospital services under the prospective payment system must conduct review of duration of stays and review of professional services for:
- For duration of stays, these hospitals are only required to review cases that they reasonably assume to be outlier cases based on extended length of stay.
- For professional services, these hospitals need only review cases that they reasonably assume to be outlier cases based on extraordinarily high costs.
Implementing Review Frequency
While the CoP states that reviews may be conducted on a sample basis, except for extended stays, most contemporary case management departments review all admissions to the hospital. Due to the changes in Medicare payments including the two-midnight rule, reductions in payment for readmissions and so forth, it has become necessary to look at all admissions at the start of the stay and daily thereafter. In the case of extended stays, less frequent reviews may be appropriate.
The UR plan should include the hospital's expectations concerning reviews for medical necessity with respect to admission, duration of stay, and the professional services furnished. If your hospital is not paid under the prospective payment system, then these rules are not applicable.
Section 482.30(d) Standard: Determination Regarding Admissions or Continued Stays
The CoP tells us that the determination that an admission or continued stay is not medically necessary
- may be made by one member of the UR committee if the practitioner or practitioners responsible for the care of the patient concur with the determination or fail to present their views when afforded the opportunity; and
- must be made by at least two members of the UR committee in all other cases.
- Before making a determination that an admission or continued stay is not medically necessary, the UR committee must consult the practitioner or practitioners responsible for the care of the patient, and afford the practitioner or practitioners the opportunity to present their views.
- If the committee decides that admission to or continued stay in the hospital is not medically necessary, written notification must be given. This notification must be given no later than two days after the determination, and must be given to the hospital, the patient, and the practitioner or practitioners responsible for the care of the patient.
Applying the Rules for Admission and Continued Stay Reviews
When someone other than a physician makes an initial finding that an admission or continued stay does not meet criteria, the CoP gives specific instructions as to how the process should be conducted. Generally, it is the case manager who is making these initial determinations, and the case manager is usually a registered nurse. However, the CoP requires that, if the criteria are not met, the case be referred to the utilization review committee or sub-group of the UR committee. This sub-group must contain at least one physician. In most hospitals, this would be the physician advisor.
The committee or physician advisor is then required to review the case. If the physician advisor agrees that the case does not meet the hospital's criteria for admission or continued stay, then the attending physician must be notified. The attending physician must be given an opportunity to present his or her views and any additional information relating to the patient's needs for admission or extended stay.
Clinical Criteria and Utilization Review
It is important to apply the role of the clinical documentation improvement specialist (CDI) into this process. For example, if you, as the case manager reviewing the record, determine that the documentation does not support medical necessity for admission or continued stay, you may also note that the patient's clinical condition and other factors seem to support the admission. Before contacting the physician advisor, you should consider contacting the CDI specialist to review the record and query the physician if additional documentation is warranted and would support the admission. In some cases, it is strictly the addition of more comprehensive documentation that is needed to support the admission or continued stay. This step should always be considered so that the physician advisor is only contacted when no other solution is available at that point in time.
The Physician Advisor
Once the documentation is in order, and the case still does not meet clinical criteria for admission or continued stay, then the physician advisor must be contacted. The physician advisor, after reviewing the case, may determine that the stay does not meet medical necessity. If the attending of record does not respond or does not contest the findings of the physician advisor, then the findings are final.
If the attending physician contests the decision of the utilization review committee or the physician advisor or if the physician of record presents additional information related to the patient's stay, then at least one additional physician on the UR committee must review the case. If the two physician members agree that the patient's stay is not medically necessary or appropriate after considering all the evidence, then their determination becomes final. Written notification of this determination must be sent to the attending physician, the patient (or next of kin), the hospital administrator, and the state agency (if a Medicaid patient) no longer than two days after the final decision, and no more than three working days after the end of the assigned extended stay period.
The CoP also points out the schedule that they expect hospitals to follow. They state that there are five working days in a week and that normally these days are Monday through Friday. They go on to say that if the hospital prefers to use a different five days, for example Tuesday through Saturday, they are welcomed to establish this in their UR plan and operations. When a holiday falls on one of those days, then the holiday is not counted as one of the five working days.
If the case manager makes a referral to the physician advisor questioning the medical necessity of an admission or continued stay, and the physician advisor determines that the admission or continued stay is justified, the attending physician is then notified. An appropriate date for subsequent review, if appropriate, is then determined and noted in the patient's medical record.
This notification must also be sent to the attending physician in writing, the patient (or next of kin), the hospital administrator and the single state agency (in the case of Medicaid) no later than two working days after the final determination is made, and in no event longer than three working days after the end of the assigned continued stay period.
For example, if the physician advisor reviews that case and determines that continued stay is approved for two days, then another review and determination must be made by the end of those two days.
Who May Make Final Determinations
The Conditions of Participation for utilization review are very clear as to who in the hospital can make final determinations regarding a patient's level of care. They state "in no case may a non-physician make a final determination that a patient's stay is not medically necessary or appropriate." This point clearly requires that the hospital have an active physician advisor in place and that all cases deemed not meeting medical necessity by the case manager are referred to the physician advisor. Many hospitals do not have this process in place and therefore would be out of compliance if audited on this Condition of Participation.
Ensuring Compliance
It is prudent to conduct chart reviews on a random-sample basis to ensure that you are in compliance with the CoP. Elements to review would include the following:
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Review a sample of records found to be medically unnecessary (not meeting clinical criteria for admission or continued stay) and determine if these decision were made by:
- One member of the UR committee, if the practitioner responsible for the patient's care concurs with the determination or fails to present his or her views.
- At least two members of the UR committee in all cases not qualified in the above bullet.
- Review a sample of records found to be medically unnecessary (not meeting clinical criteria for admission or continued stay) and verify that the physician was informed of the committee's expected decision and was given an opportunity to comment.
- Review a sample of records found to be medically unnecessary (not meeting clinical criteria for admission or continued stay) and verify that all involved parties were notified of the decision that care was not medically necessary no later than two days following the decision.
Section 482.30(e) Standard: Extended Stay Review
The CoP refers to long-stay patients as extended stay. They define extended stay as patients whose length of stay has reasonably exceeded the threshold criteria for the diagnosis as determined by the hospital. This threshold is determined by the prospective payment system's expected length of stay for the diagnosis-related group and then the hospital can define what it considers to be extended beyond that. The hospital is not required to review an extended stay that does not exceed the outlier threshold for the diagnosis.
The utilization review committee must review the record no later than seven days after the day required in the utilization review plan. Therefore the UR plan must include the hospital's own definition of what an outlier patient is.
This section of the CoP is dependent on a definition in the UR plan that specifies what the hospital considers an extended stay. Most hospitals use this definition to review cases for medical necessity but also for delays related to discharge planning issues.
Defining Long Length of Stay (Extended Stay)
Most hospitals define long length of stay as cases that exceed a pre-determined length of stay. For the majority of hospitals, this is stays with a length of stay greater than seven days. If however, you find that this length of stay leaves too many cases to review, you can change your definition to greater than ten days. The frequency of review of these cases should also be defined in the UR plan. Best practice calls for weekly review of these cases to ensure that progress is being made and interventions are happening as needed.
While not common, some hospitals may use different thresholds for different diagnoses. If your hospital chooses to do this, then there must be a written list of the lengths of stay for each diagnosis. Clearly this can be a cumbersome and difficult process to operationalize and is why most hospitals choose to have one extended stay threshold that applies to all patients.
The review of these cases should be included in the minutes of the utilization review committee.
Audits
If the hospital's utilization review plan and process are audited, the auditor will review the minutes in addition to discussing the process with the case management staff. Each case manager should have a copy of the UR plan and should be familiar with it. If the hospital has an intranet where documents are kept, the UR plan can be kept there as well.
Summary
As case managers, the UR plan and the CoP are important tools that guide our daily work. It is important to be familiar with all CoPs that apply to case management and to review these on a regular basis!
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