Hospital Utilization Review Plans

Hospital utilization review plans are the documentation that determine how long a patient stays in a hospital for treatment or even if the patient is admitted to a hospital for treatment. It a process aimed at providing quality patient care in a cost-effective manner, reducing hospital admissions and lengths of stay in medical facilities. It compares proposed treatment options to national averages and standards, and is used to determine whether private insurance companies or government-backed Medicaid covers hospital lengths of stay.

Certification

• Justification is needed for any medical procedure or hospital stay before an insurance company will cover payment--excluding emergency medical situations. Once hospital admission is approved, a length of stay is assigned by a physician reviewer, nurse reviewer, hospital panel, insurance provider or some combination of the four.

  Cost-effective and alternative treatments are discussed between insurance representation and the attending physician or hospital rep. When the course of treatment is decided upon, a length of patient stay is determined based on national averages and standards for that treatment option.

  For elective procedures, certification can be as simple as a telephone call to a hospital review nurse from an individual's doctor.

  In emergency situations, the patient's family or doctor normally must contact the insurance provider within 24 hours or on Monday (or the next working day when a holiday occurs) for a weekend emergency procedure. A medical expert for the insurance carrier reviews the case and determines the appropriateness of the emergency care and if any further hospitalization is needed for the patient.

Under Review

• While many people may think insurers cut patient hospital stays at all costs, there are national criteria that must be met for a care decision that is made.

  When an elective procedure is certified, an initial length of stay is determined for the patient. If the patient has not left the care facility by the end of that initial time frame, further information is needed from the attending physician and the case is given further review. If the insurer determines that continued care is justified, a new discharge date or case review date is determined.

  If continued care is not justified by the insurance carrier, the patient must be discharged or an appeal must be made.

  There are opportunities in the program for physicians to make a case for a patient's continued treatment or remaining in the hospital due to extenuating circumstances.

Why the Rush?

• Getting patients out of hospitals and into their homes or alternative treatments as quickly as possible is a cost-saving measure aimed at keeping medical costs to a minimum.

  As soon as a person enters the hospital, a discharge plan is put into effect in hopes of getting the person out of the facility as quickly as possible due to the normally higher medical care costs associated with hospitals.

  Case managers, hired by insurance companies, are often used to work out discharge plans with hospitals and physicians.

  Should questions arise about care after a person is discharged, a board of specialists normally will address the case and make a decision on whether care steps taken were appropriate or if the length of stay was appropriate. That decision determines insurance coverage for those procedures.