Medicare Utilization Review Requirements for Inpatients

Utilization review refers to the process of reviewing Medicare cases after health care services are conducted to determine the medical necessity of services as well as the appropriateness and efficiency of treatment under the applicable health benefit plan. Utilization management, a term sometimes used interchangeably by the medical community, actually refers more to managing procedures such as discharge planning and clinical case appeals.

Review Process

• After an inpatient stay, a case is reviewed by a nonphysician. If the case is found by this initial reviewer not to meet inpatient criteria, the case is given to a physician reviewer to determine if the stay was medically necessary. The physician reviews the stay to determine if criteria exist that necessitated the inpatient admission. If this is the case, the physician approves the stay. If hospital records do not show compelling reasons for the stay, the case is not approved. In these cases, the hospital treatment team has an opportunity to provide information that was not included in the initial review. The case is reviewed again by a second physician. If the case is denied on the second review, the case then moves to an Administrative Law Judge (ALJ), who makes a final determination. If the ALJ denies the claim, Medicare reverses payment for the hospital stay.

Necessary Information

• When organizing information for the utilization review, it is important to include all pertinent data regarding demographics, symptom intensity and specifics of the discharge plan. While vital to the process, submission of this information does not guarantee payment.

Demographics

• Demographics information includes the patient's name and identification number as well as the name and contact information of the attending physician and the dates of hospital admission.

Symptom Intensity

• Indicating the level of illness determines if inpatient stay was a necessity. Include the main clinical issue, vital signs, intensity and character of pain and neurological state. A brief description of both normal and abnormal diagnostic tests is vital to the claim, as are any consultations or procedures performed.

Service Intensity

• It is important to include not only the type of service the patient received, but also the intensity or frequency. For example, if IV medications were administered, indicate the dosage and frequency. Any medications that were given for nausea or pain should be indicated along with the dosage and frequency. Also include any IV fluids or total parenteral nutrition, blood products or oxygen. If the patient is diabetic, indicate high and low blood glucose readings during the hospital stay, as well as any units of insulin the patient received above routine daily dosing. If wound management was necessary, describe both the wound and the treatment performed. Include any other treatment or therapy necessary during the stay as well as the indications for such.

Discharge Plan

• It is necessary to indicate the patient's long-term plan of care, including disposition, educational and home service needs after discharge and any psychosocial issues that are present.