Presentation Overview

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1 MISSING VITALS: IMPORTANT INFORMATION FOR UTILIZATION REVIEW 2011/2012 Presentation Overview Utilization Review HFS Requirements Vital Information for Review Clinical information necessary Completeness and accuracy of information Review Process Nurse Review Physician Review Provider Education Resources Q & A Session HFS Requirements Contracted by Healthcare and Family Services (HFS) to perform review services for acute inpatient care of HFS medical program participants to ensure: Medical necessity Reasonableness and appropriateness of care Completeness, adequacy and quality of hospital care Quality of services meet professionally recognized standards of care Validity of diagnostic and procedural information supplied by hospital Whether services could be effectively furnished at a lower level of care (i.e. observation) 1

2 Medical Necessity Appropriateness Discharge Readiness Limited Scope Vital Information for Admission Review Additional diagnoses or procedures (PerDiem reviews) Vitals/Labs report vitals and tests with positive or abnormal results, or relevant to diagnoses (i.e. include 02 sat, UDS, etc) Findings, Treatments, Diagnostics, Imaging check off those performed or ordered and results in comment field i.e. EKG: NSR, prolonged QT Treatment plan and medications All IV, IM and SubQ Meds and PO Meds if being titrated, frequency of PRNs in 24 hours. Precautions/locked unit for psych. Enter medications in med grid Discharge plans give d/c summary at each review Short Clinical Summary Where patient came from (i.e. home, nursing home) Why was patient admitted? Include admit signs and symptoms Patient medical history Outpatient treatments? Co-morbidities? Any medical conditions present on admission? Information Needed for Continued Stay Reviews PerDiem Reviews Provide supplemental clinical information to substantiate medical necessity for each day of care Start clinical information for all requested days from last day certified; or last 24 hours Any additional diagnoses or procedures? Labs/tests/diagnostics? o Results of any pending labs/tests Any changes in treatments and medications? o Change status in med grid. Same med? Changed? Progression/regression of signs and symptoms DRG Discharge Reviews Quality Screening at time of discharge Clinical summary of last hours. Indicate patient disposition, resolution of signs/symptoms, final lab/test results and discharge plans. Include any hospital-acquired conditions (i.e. falls, injuries or med errors) 2

3 Information Needed for Cont Stay Reviews - Long Term Acute Care Reviews Information to show continuous, intensive level of care Give quantitative measures For all therapies, give frequency, i.e. 5 days per week and how long? Is patient participating? Example: Wound care >1 hr qd, suctioning every 3-4 hrs, sliding scale insulin coverage 2-4x qd, etc. Any new labs/tests/diagnostics since last review point? Change in treatments and medications? Must show discharge planning at each review point Note any setbacks in progress List fevers, poor tolerance of tx, meds, etc. Retrospective vs. Scope (Limited) Medically necessary & appropriate Discharge preparedness (Broad) Medically necessary & appropriate Check for critical billing errors Full medical record review ICD-9-CM billing and DRG coding validation Full Medical Record Review Complete and accurate information Mandatory Medical Record Components Physician Orders H & Ps Progress Notes Vitals and Labs/Diagnostics Treatment Plan and Meds Discharge plans and status eqhealth Solutions Verifies Billing codes, including DRG Signed/dated order for inpatient admission Billed vs. inpatient admit date Medical record information supports information given for concurrent review Medical necessity of each day of care Quality of care 3

4 Top 3 Reasons for Cancellation Critical Billing Errors 1. Missing order; or no clear order to admit to inpatient; or no order to convert patient from observation to full inpatient status 2. Incorrect inpatient admission date per physician order to admit to inpatient care (signed and dated order) 3. Incorrect discharge disposition code Billing Error Common Example 1. Missing order; a) no order to Example Physician Order: admit to inpatient or b) no order a) 1/1/2011 Admit to 3 west; or to convert from observation to b) Inpatient box is checked but inpatient status no date or physician signature 2. Incorrect inpatient admit date Example: Observation date is billed as the inpatient admit date 3. Incorrect discharge disposition code Example: Claim shows Discharged Home, but hospital documentation shows discharged to another acute care facility or left AMA Hospital Receives Review Cancellation Notice for Billing Error Rectify the error and adjust the claim Send correct claim for services to HFS HFS selects for prepayment review eqhealth sends another Notice of Selection of Medical Records to hospital eqhealth Liaison 4

5 Utilization Review Process Applies to both Mandatory Concurrent and Retrospective Prepayment Review Process Nurse Review Apply InterQual 2011 criteria sets Severity of illness Intensity of service Discharge screen Utilization Review Process Nurse Review Outcomes With hospital-supplied clinical information Certify Pend Requires additional information to satisfy criteria Refer for physician review Does not satisfy criteria and/or length of stay norms beyond nurse certification Physician Review Referred to Physician for Review Matched by physician specialty Assigned to physician peer reviewer (PR) who reviews hospital-provided clinical information Admission review information given for review Retrospective review copy of medical record Physician Review Outcomes Certify Medical Necessity Denial Admission or continued stay days Change in DRG 5

6 Appeal Process Physician Denial/DRG Change The hospital or physician may appeal by submitting a written request within 60 calendar days of eqhealth notification of : Medical necessity denial or Change in DRG eqhealth Reconsideration Form & Supplemental Information (only for days denied) Less than 10 pages may be faxed to 800# on form More than 10 pages, send to eqhealth address on form Hospital will receive a Notification of: Receipt of Reconsideration Request ; or Cancellation of Reconsideration Request (untimely) Provider Resources eqhealth Provider Helpline Monday through Friday, 8 am to 5 pm Online Helpline available Website Provider Resources for Web guides, FAQs, UR Manual, etc Web system eqsuite Web-based review system Reports with real-time and historic review data Education and Training Rose Serno, Provider Education and Outreach Representative rserno@eqhs.org 6