The Hospital UR Plan

by Stefani Daniels, Managing Partner
Published on Jan 27, 2016

A solid UR plan should provide clarity of purpose and application of processes as they relate to managing regular Medicare and Medicaid patients through each acute episode of care, from admission to discharge.

Does your hospital have a UR plan?  If your knee-jerk reaction is "sure, we do," think again.

When the Revenue Cycle Manager, Director of Utilization Review or VP of Case Management are pressed to produce the hospital's UR plan, these leaders are often chagrined to find that the latest edition of the plan is 3 to 10 years old, has never been approved by the Board of Trustees or the Medical Staff, and is woefully inadequate in the world of RAC, MAC and ZPIC auditors.  If your plan has not been reviewed, revised or endorsed by the Board during the last year, this could be a significant problem. The UR plan establishes the organization-wide process for utilization review and resource (utilization) management. It should incorporate care management and utilization review activities even if your programs are separate since care coordinators are the primary advocates for real-time resource efficiencies.  The plan should cite a mechanism of sharing utilization outcomes via the organization's utilization review committee (URC) which is the ONLY committee federally mandated.

A solid UR plan establishes the processes that demonstrate compliance with the CMS Conditions of Participation.  Those processes should be followed consistently every time, all the time by utilization review specialists who maintain expert proficiency.  Anything less may result in devastating revenue hemorrhage and the risk of attracting the attention of the OIG.  The UR plan should include a widely accepted, current and uniform set of admission criteria that is used to determine if medical documentation confirms a patient's eligibility for acute level of care.  The plan should also identify a second level review process by the physician advisor/medical director when questionable use of hospital resources are present.

At the end of the day, a hospital's UR process is evaluated against its own UR plan.  If the actions of the utilization review specialists are contrary to the plan specifics, the hospital is at risk.  In the world of CMS and audit contractors, there is no right way to do the wrong thing.  Establish a process via your UR plan and stick to it.  A solid plan, reviewed and revised annually, is critical for revenue integrity, compliance with regulatory and contractual expectations, and the hospital's ability to defend itself against the force of commercial and federal auditors.      

For more insights on the elements of a solid UR plan, see our latest publication:  The Hospital Guide to Contemporary Utilization Review.