This program will cover the CMS (Center for Medicare and Medicaid Services) hospital Conditions of Participation regulations for Utilization Review. Every hospital that accepts Medicare and Medicaid reimbursement must be in compliance with these standards. Compliance with the UR standards is more important to avoid penalties from the Recovery Audit Contractors (RACs) and other organizations such as the OIG.

Preventing unnecessary readmissions is essential. Hospitals that have a higher rate of readmission now receive less money from CMS. This is why there is increased surveillance activity in the area of discharge planning.

It is important to establish medical necessity especially in light of the RAC program so hospitals do not have to pay back the money. So what’s in your UR plan? This webinar will discuss what is typically found in a UR plan.

This program will discuss why hospitals get cited by CMS. Information will be provided about the deficiency reports.

Does your hospital have a contract with your state QIO? Is there concise documenting in the chart regarding medical necessity and compliance with the two-midnight rule? This program will also discuss the MOON form required for outpatient observation patients.

Session Outline:-

Utilization Review

• Utilization Review under Tag 652
• Introduction
• How to keep up with CMS changes in the future
• How to locate a copy of the CMS UR Requirements
• Last changes regarding accreditation organizations assessing compliance with UR standard
• 3 tag number revisions 
• CMS deficiency reports and why hospitals get cited
• UR plan required
  • Must include a review of services provided to Medicare and Medicaid patient
• Joint Commission adds UR plan and committee standard
• If QIO contract, the surveyor will not assess the remainder of UR standards
• UR plan requirements
• Goals of a UR plan
• Activities performed in UR plan
• Functions of a UR committee
• Choosing Wisely and Image Wisely
• Conflicts of interest
• Agreement with QIO
• BFCC QIOs
• State UR procedures
• MOON Forms for outpatient observation patients
• Review of physicians and non-physician providers
• Composition of UR Committee
• Frequency of reviews
• Observation versus inpatient admission
• Scope of reviews
• Admissions or continued stay
• Medical necessity determination
• RACs and medical necessity
• Non-physician determinations
• The two-midnight rule (on hold)
• Medical necessity
• Intensity of services
• Discharge screens
• Documentation of the decision-making process
• Moon form and changes to the IM and detailed notice

Objectives:-

• Recall that the hospital must have a UR plan
• Discuss the importance of documentation of medical necessity by the physician in the medical record
• Describe that hospitals are required to have a UR Committee
• Recall there are three revised tag numbers 

Who Should Attend?

Anyone involved with the UR process or anyone who is required to comply with the standards. This could include the following:

• Case Managers
• Utilization Review Committee
• Transitional Care Nurses
• Social Workers
• Discharge Planners
• Chief Nursing Officer
• Compliance Officer
• Risk Manager
• Regulatory Officer
• Physician Advisor
• UR Nurses
• Joint Commission Coordinator
• Nurse Educators
• Chief Operating Officer
• Chief Executive Officer
• Business Office Manager
• Health Information Director
• Billing Office Director
• Chief Medical Officer
• Nurses with Direct Patient Care
• All Nursing Directors and Managers
• Anyone Else Involved with the UR Process