Utilization Review/Management and Accreditation Flashcards
Utilization review
Written program that strives to ensure appropriate allocation of the organization’s resources (money, staff, time) by trying to provide quality patient care in the most cost efficient manner
Process to establish guidelines through an effective review process
Focus of Utilization review
Territory between quality and fiscal management
Review of a prescribed course of medical care - it is a review of how care is provided and is it appropriate
Purpose of Utilization review
To improve quality of care so there is not under or over utilization of resources
Ensure the level of care is appropriate in quality, timing and resources
Process to contain costs
Purpose of Utilization review - example of under utilization
Ortho floor of hospital where no OT services are used for total joint replacements
Purpose of Utilization review - example of over utilization
Every pt admitted to hospital floor gets order for PT eval
Another purpose includes Cost Containment - what is cost containment
Process to control expenses and save money
Prevention of extensive spending
3 processes that are used to contain costs
- Pre certification
- Admission
- Concurrent
Another purpose includes Cost Containment - Pre certification
Control of costs before admission or tx
AKA pre authorization
Medical necessity is established before services are provided
Ex - PT office contacts client insurer to establish medical necessity before providing services
Another purpose includes Cost Containment - Admission
Upon admission, costs are determined for care
Initial exam is completed and POC is developed and further auth is obtained to continue tx
Another purpose includes Cost Containment - Concurrent
Process to approve continuation of care for only as long as necessary
Focus on ongoing care for pts and determining best course while containing costs
Includes reviewing the need for further hospitalization or tests
Care coordination - Utilization Review
THis is an approach to healthcare in which all of a patient’s needs are coordinated with the assistance of a primary point of contact (social worker or care coordinator)
Focus is on outcomes, patient experience and cost
Utilization review plans are what
Mechanisms that are in place to address inefficiencies and utilization of resources
THEY SHOULD BE WRITTEN!
Utilization review plans are developed with
input and approval of all involved parties - Ex: multidisciplinary team of PT, OT, nurse, ortho sx - all develop a plan to include OT services for pt status post total joint replacement
Utilization review plans - should be reviewed
And revised annually to ensure appropriateness!
Claims review is what
Process used to assure that claims are accurate, reasonable and appropriate for services that have been provided or will be provided
Claims review includes what
Internal Audit
Claims eligibility
Policy review
Claims review - Internal audit
Process to review a medical claim to ensure accuracy
Can be retrospecitve or prospective
In retro - if error found and healthcare entity received payment, they need to return payment and could be penalty
Claims review - Claims eligibility
Process to ensure that the healthcare visit qualifies for coverage from pt insurance
Might be some restrictions that should be determined prior to beginning care
Ex = 3rd party payer approves 5 visits, PT has to track number of visits and complete request for more if pt owuld benefit
Claims review - Policy review
During policy review, benefit coverage is determined
Membership is verified, coverage status and other info like applicable co payment, coinsurance, and deductible amount for healthcare visit
Program evaluation
Systematic process to review a particular program to ensure it is effective and efficient and meeting outcome for the clients
Done continuously - helps to determine discrepancies between actual and expected outcomes
Program evaluation - process
Evaluation of effectiveness
- Identify and define program’s objectives and compare to outcomes of service provided
Ex - determining # of sessions, change in function, cost of services, and discharge status/destination of persons served
Evaluation of efficiency
- comparison of identified outcomes and utilization of resources
Examples - determining cost per outcome or cost per intervention/session
Must use reliable tools for accuracy!!!
Program evaluation - data
Reviewed from risk management, quality management, utilization review, and claims review activities of the program
Program goals, outcomes, and resource utilization are evaluated and compared to a set of explicit standards
Program evaluation - utilization of information
Used to support short term and long term decisions
Determine if program is woth while
Are there better alternatives
Are the goals appropriate
Are there any unintended consequences of the program
Program evaluation - reasons for completing
Accreditation requirement
Helps determine why you might be over or under budget
Provides info when making decisions
Provides info to support program development efforts
Can determine program effectiveness
Should be done annually, when starting a new program and when there are changes in the environment or program
Accountability in healthcare
Expectation of quality care and achievement of reasonable and predictable goals
Providers are utilizing resources wisely
Proof of performance is accessible
Achieve the best quality outcome with the least amount of risk
