Written by Lisa Young, MSN, RN, CMCN, CEN, CHCQM, Manager of Care Management, McBee

Utilization management (UM) is a cornerstone in the fiscal success of healthcare organizations and an essential component of the complex revenue cycle. A pivotal tool, utilization review (UR) is a proactive approach in evaluating hospital admissions. The critical role of UR involves concurrent review of the clinical encounter by skilled, seasoned registered nurses, and the application of standardized, evidence-based criteria to evaluate the medical necessity of the hospital admission. This provides organizations with the ability to better manage costs, reduce unnecessary hospital stays, manage length of stay, improve revenue reimbursement, and improve the overall quality of care. There are many inconsistencies between organizations in UR processes and workflows, qualifications of reviewers, and application of the criteria tools used to support medical necessity.

One method employed to address and evaluate these inconsistencies is with an internal quality review program. This quality review process ensures consistency across all reviewers, as well as with the application of the criteria tools. The goal of the program is to mitigate human error by the clinical reviewers evaluating the encounter, and potentially reduce the risk of a concurrent denial from the insurer. In addition, emphasis on accuracy and consistency of the review process will also aid in supporting a secondary reviewer’s response to a payor decision with a peer-to-peer conversation.

This quality review process includes several facets. With the criteria tools, each product has its own interrater reliability testing. Each clinical reviewer should be required to complete this assessment annually. They should strive for a score higher than the minimum passing score recommended within the tool itself. Leveraging the annual assessment keeps the clinical reviewer knowledgeable in the criteria and instills a standard of excellence surrounding the utilization review. Their tasks (completed accurately) are essential to ensuring proper and complete revenue is generated and minimizing hospital losses while keeping the patient in the proper setting.

Another process applied in evaluating quality is a sampling review of individual cases. This includes evaluation of documentation, the selection and application of criteria within the review, and completing follow-on process workflows accurately based on the review outcome. All clinical reviewers should have a standard percentage of their total volume of reviews evaluated on a monthly basis. Scoring of each case review should be weighted based on the significance of the question, with each case receiving a calculated score. For example, selecting the appropriate criteria is weighted at 25 percent of the total score for the case, resulting in a failing score if the correct criteria are not applied. Individual reviewers receive written feedback regarding any case that does not receive a passing score, with education and clarification of the correct application, based on the documentation and criteria reviewed.

On a monthly basis, quality review scores should be provided both to the individual reviewer, as well as the overall quality score for all cases reviewed by the facility being supported by the UR team. Within the quality review program, those reviewers falling below a 95 percent passing score would have an increased standard percentage of their cases examined for accuracy. The standard percentage of cases reviewed is based on a grading scale, up to 50 percent. For reference, new clinical reviewers should have 100 percent of their work evaluated for quality in the first two weeks working independently to ensure success after training. The reviewer’s quality review score is used to support the management of their performance on an ongoing basis. This robust quality review process sets the standard for the UR program.

The internal quality review program also assists in identifying trends with reviewers’ interpretation and application of the standard criteria tools. This provides opportunities for clarification and education amongst the UR team. A few examples include the following:

• use of inpatient-only surgical lists,
• therapeutic versus prophylactic anticoagulation dosing,
• use of physical and occupational therapeutic evaluation and therapies.

Noting these common elements and potential for human error affords the UR program the ability to continually improve the quality of the clinical reviews by reducing variation and error.

This program evaluates the quality of the admission and continued stay reviews completed by the UR team. Quality review scores are provided to both the individual reviewer, as well as organizational leaders to evaluate the overall quality of the UR team. Providing reliable, quality UR support ensures that criteria tools are correctly utilized, that medical necessity decisions are supported, and patient status is accurately reflected. With quality assurance review, UM leaders can be confident in the integrity and consistency of the review outcomes, extending the UR team’s impact on the organization’s revenue cycle. These impacts are demonstrated through more precise billing and streamlined claim reimbursement, potential reduction in concurrent denials, more robust support in the appeals process, and a discernible influence on the average length of stay.