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
Organizations that set standards for health care providers
Governmental agencies - CMS, DIA Professional associations - APTA, AMA Consumer advocacy groups - AARP Third party payers - BCBS Accrediting agencies - joint commission
Accreditation
Review process of health care organizations to determine if it meets predetermined criteria standards of accreditation established by a professional accrediting agency
An entity is given accreditation after
they have demonstrated compliance with the performance or competence standards of the accrediting organization
Accreditation standards are the
basic standards against which an entity is measured in evaluating its fundamental elements
Accreditation - To participate and receive payment from CMS, an organization must
be certified that it follows CMS standards
This certification can be achieved by a survey by a state agency or a national accrediting organization that CMS granted authority to certify organizations
Commission on Accreditation of Rehabilitation Facilities (CARF) -
International, non profit, non governmental agency that accredits health and human services
Surveys hundreds of thousands of programs throughout north and south america, europe, africa, asia
Achieving accreditation demonstrates a commitment to quality improvement and on the needs to each person the provider serves
Commission on Accreditation of Rehabilitation Facilities (CARF) - Purpose
Improve value of life enhancement programs and services promoting quality, value and outcomes
Recognize organizations that demonstrate commitment to continuous improvement of their programs
Support organizations through consultation, education, training, and publications
Provide information and educate others on the value of accreditation
Commission on Accreditation of Rehabilitation Facilities (CARF) - Process
Starts with organization completing review of its programs and business practices
Request on site survey
During survey, CARF team compares the organization to CARF standards
Receive a report of strengths and areas for improvement - organization must address any areas of improvement
Earn CARF accred
- 1 year conditional if improvements needed
- 3 year full if standards met adequately
Commission on Accreditation of Rehabilitation Facilities (CARF) - programs
Adult day services Assisted living Behavioral health Child and youth services Employment and community services Medical rehab
Commission on Accreditation of Rehabilitation Facilities (CARF) - Benefits to be accred by CARF
Evidence that your organization strives to improve efficiency, fiscal health, and service delivery
Third party payers, gov agencies, and public recognize CARF accrred as a commitment to excellence and accountability
CARF accred signifies a stamp of approval that you are meeting established standards
The Joint commission (TJC)
Independent, not for profit organization
Certifies nearly 21,00 health care organizations and programs in US
The Joint commission (TJC) - purpose
Certifies organizations and programs that meet minimal standards
Committed to quality health care
Accepted by CMS to certify providers/organizations to provide services to medicare beneficiaries
The Joint commission (TJC) - process
Unannounced survey about 18-36 months after you’ve had a previous survey
Review organization according to set standards (like hand washing - infection prevention, or pt identifiers - national pt safety goals)
TJC reviews operations and uses tracer method - the will identify a pt and follow the course of their tx
At conclusion - fully accred or requirements for improvement before receiving full accred or does not receive accred
The Joint commission (TJC) - programs
Ambulatory care, assisted living, bx health care, critical access hospitals, health care networks, home care, hospitals, lab services, long term care, office based surgical centers
Also - disease specific programs like heart failure, chronic kidney disease, COPD, inpt diabetes…. primary stroke center
Additional requirements and clinical guidelines to receive those certifications
The Joint commission (TJC) - benefits
Improved pt care due to commitment to safety and quality
Strengthens consumer confidence
Improves risk management and risk reduction
Provides competitive edge in the market
Provides education on good practice to improve operations
Provides professional advice and counsel
Recognized by select insurers and other 3rd party payers
Utilization review =
ENSURES APPROPRIATE ALLOCATION AND USE OF ORGANIZATIONS RESOURCES
Risk Management =
IDENTIFIES POTENTIAL THREATS AND TAKES ACTION TO AVOID ADVERSE EVENTS
Program evaluation =
DETERMINING THE EFFECTIVENESS AND EFFICIENCY WITH WHICH OUTCOMES ARE ACHIEVED
Quality management =
REVIEWS PROCESS TO ACHIEVE MAX CUSTOMER SATISFACTION
