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
