The Breakdown on continued stay reviews

by Tiffany Ferguson, LMSW, CMAC, ACM
Published on Sep 09, 2021


A recent question was asked: “how often should UR (utilization review) complete continued stay reviews for Medicare FFS (fee-for-service) patients?” 

Well, a host of answers appeared across the healthcare industry; however, the response I gave was this:

The level of UR involvement is dependent on how highly functioning your care management/care coordination (CM/CCs) folks are. Who is watching resource utilization and the progression of care (or lack thereof?) 

If your hospital ensures that CC/CM is doing this, great; that is the ideal scenario. Clinical documentation improvement (CDI) will be looking at your inpatients, but UR needs to be watching the outpatients. CDI also may not be looking at continued medical necessity – this is typically a UR function.

Depending on your person responsible for medical necessity, UR needs to be looking at the progression of care and patients ready for discharge – and making sure it is made known when they no longer meet medical necessity. This is defined by any process your hospital can create, and does not require a full review. I like the geometric mean length of stay (GMLOS) time frame as a quick review to see why patients are still admitted inappropriately, and to track avoidable days (as well as help my CC/CM or CDI counterparts with any red flags).  

Let’s give a more detailed breakdown of what that all means. We often find UR specialists hunting for the green light in their criteria guidelines tool to get patients to meet inpatient criteria, then completing the follow-up tasks necessary for continuing to make sure that the green light exists in the system to justify the patient’s presence in the hospital. 

Evidence-based guidelines are important to consider when evaluating patient appropriateness for inpatient treatment, but we must first remember that the Centers for Medicare & Medicaid Services (CMS) mandates that the intention of hospitalization be based on medical necessity. There is also the expectation that the patient’s treatment will require at least a two-midnight stay, which needs to be reflected in the medical documentation. 

The Utilization Review Accreditation Commission (URAC) defines UR as the evaluation of medical necessity, appropriateness, and the efficiency of the use of healthcare services, procedures, and facilities under the provisions of an applicable health benefits plan.

The UR specialist has the important task of evaluating whether the medical record matches the clinical picture for revenue integrity, in order to ensure that the patient’s hospitalization and services are reasonable and necessary. At the point of admission, the UR specialist will examine the record to pose the question: does the patient need to be hospitalized? If not, why? If so, have we ensured that the clinical picture in the record matches the level of care assigned? Now, once the patient is in the hospital, what must the UR specialist do to ensure that the patient continues to need hospital services?  

For commercial contract patients, the answer is always “check your contract.” The contract will determine how often updated clinicals need to be sent for reviews, discussions, and conversations with the UR counterpart on the payor side. For Medicare, I urge my UR specialists to question the traditional two-day rule and the busywork of checking the criteria guidelines to say, “yes, they still meet criteria.” Instead, let’s remember the following from my friend and advisor Stefani Daniels: length of stay is not a problem; it is a symptom of delays in progression of care due to system inefficiencies. The concurrent review should be performed in collaboration with your care coordination/case manager counterpart and physician advisor extraordinaire, to advocate for the progression of care and resource utilization of the organization. This can occur in any fashion, and on any day you choose to do it. I would say attend interdisciplinary rounds and get the scoop on what is going on with each patient. If you are in a health system where this is not possible, then utilize your artificial intelligence system to look for mismatches or your GMLOS to see which patients require a closer look. 

Determining why the patient remains does not necessarily require a complete criteria review. Instead, look at the documentation and see why the patient is still here, what are they receiving, and what the plan is for progression and transition of care. You will want to be on the lookout for documentation that shows clinical justification that needed care cannot safely be provided in a lesser setting. Also, check for incidentalomas and “while you are here” testing. Both can put the patient at more risk, are likely not reimbursed, and can be more effectively coordinated after discharge in an outpatient setting. If something is missing in the documented picture, then again, let’s rely on our team members for effective support and communication to ensure appropriate transition of care. 

Finally, let’s ensure that we have a collaborative and healthy conversation with our attending to educate and support the patient’s continued need for hospital level of care. Please remove the saying “your patient no longer meets criteria.” What does that mean? Who says? Instead, try a starting conversation that respects the physician perspective, with language such as, “help me understand and support your plan. I read your note, but still have some questions. Can you help me bridge the gap on what you are thinking for this patient’s plan of care?” Then we can move forward, with the avoidance of you shouldn’t, and you can talk about how your CC/CM counterparts can facilitate those services in an outpatient setting.