Moraine Park Health Center Utilization Review Plan 2013

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Moraine Park Health Center Utilization Review Plan 2013 Executive Summary Utilization management is a set of processes used to evaluate individual cases to determine the appropriate and effective use of medical services. The utilization review (UR) plan looks at treatment outcomes to see if the services provided were appropriate and cost effective. Moraine Park Health Center (MPHC) is required to have a utilization review (UR) plan in place to comply with federal regulations and maintain JCAHO accreditation (Spath, 2013, p.122, 123, 124). CMS Standard: • 42CFR482.30(c) (1) standard: Scope and frequency of review. “The UR plan must provide for review for Medicare and Medicaid patients with respect to the medical necessity of— • – (i) Admissions to the institution; • – (ii) The duration of stays; and • – (iii) Professional services furnished, including drugs and biologicals” (CMS, 2013). JCAHO Standard: • LD.1.30 “The organization complies with applicable law and regulation. o Elements of Performance  1. The organization provides all services in accordance with applicable licensure requirements, law, rules, and regulation” (University of Michagan, n.d.). The UR plan activities are directly tied to Mac Audit and coverage requirements. (Spath, 2013, p.128). Purpose & Goal of Plan The purpose of the plan is to determine medical necessity, quality of care, appropriate level of care, and efficient use of resources. The plan goal is to support MPHC’s Mission, of providing quality care, improving patient safety, and reducing costs by the collection and review of data to identify under and over utilization of resources and unsure patient treatment meet best practices for the care provided. Program Structure The UR Plan Committee includes representatives from Physicians, Nursing, Administration, Quality Management, Admission and Discharge coordinators, and Health Information Management. The UR Plan directs the committee activities and reporting hierarchy. A Utilization Review Coordinator is appointed by the committee and responsible for: Measurement and assessment of • Level of care • Resources • Discharges • Evaluate identified problem cases to identify under and over utilization of resources • Performance measures and improvements o ALOS o Average total charges o Average profit margin o Number of hospital days denied reimbursement (Spath, 2013, p.129) Discharge planning • Track patients from admission to discharge o Ensure effective use of resources • Develop discharge plan o Ensure coordination and continuity of care (Spath, 2013, p.126, p.131) Program Process The UR plan guidelines are used to assess patient care and assure services are necessary, appropriate, and meet regulatory and clinical guidelines (Spath, 2013, p.126). These goals will be met through a monitoring and review process. Review Methodology and Rationale There will be three types of reviews conducted, prospective review of admissions, physicians, and medical records, concurrent review of new admissions for medical necessity and appropriateness, and retrospective review to focus on denied claims and identify cases of under and over utilization of resources.
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