When Fredonia (KS) Regional Hospital looked into updating its utilization review program, it focused on two key areas: involving the right people and being aware of its communication with the medical staff and its bylaws.
The goal of the program was to ensure that hospital resources were being allocated appropriately with the goals of maintaining quality patient care; achieving the best possible efficiency of hospital resources; promoting quality of care through the right level of analysis, review, and evaluation of clinical practices; and, of course, ensuring that the care being provided was medically necessary and appropriate.
"We had an existing utilization review policy, and it wasn't very effective," says Pam Harmon, RN, LNC, chief nursing officer at Fredonia. "We needed to be more diligent."
What they needed, she and her colleagues realized, was an active committee to help get the medical staff aligned with the most up-to-date utilization policy.
But first things first: involving the right people. As a starting point, Harmon reached out to the record review committee. The team also sought feedback from the organization's utilization review nurse.
Billers and coders were equally represented.
"I was previously unaware of the separateness of those two roles," says Harmon. "The billers, coders, business office, and medical records office all have specific jobs which, while we might think of them together, are completely separate in their minds. We needed to go beyond inviting just someone from the business office and medical records."
They also invited a social worker to the committee.
"She has so much to do with people being compliant in finding the right services," says Harmon.
The team was rounded out by the discharge planner. Additionally, Harmon suggests including the corporate compliance officer on the committee.
Once the right team was in place, the research began in earnest.
"We took a lot of information about what [various agencies] were looking at, things we needed to do for demonstrating medical necessity," says Harmon. She also searched online for sample policies from successful organizations to run side-by-side comparisons with her own organization's utilization policy.
"I set down what we were actually doing versus what we wanted to do," says Harmon.
The timing of this review was important as well—changes nationwide have put a focus on utilization in ways the healthcare community has not encountered before.
"Prior to healthcare reform, this was an area that at least half the country wasn't paying attention to—we weren't getting denials," says Harmon. "If anything had come back, hospitals could go back through the chart and fix it. This is no longer the case. We really need to get on top of this. We as an industry needed to fix it so we wouldn't get denials."
Also, with the concept of medical necessity looming on the horizon, hospitals need to be even more aware.
"When we get letters back, we try to make adjustments to make it fit. Hopefully we'll get less letters down the road, less denials," says Harmon.
Fredonia is a small hospital—a 25-bed critical access facility—but Harmon and her colleagues realized there must be one person charged with tracking utilization review full-time.
"You are going to lose a lot by not having someone focus on it every day," says Harmon. "This is a vitally important part of your hospital's operation plan."
Medical staff involvement
In order to implement this change in policy, Fredonia knew it would need medical staff buy-in. The hospital chose a representative of the medical staff to be a part of the development process and a standing member of the committee.
Harmon recruited one of the hospital's younger physicians to be on the committee. The thought was to find someone young enough to be open to new methods for discussing utilization review.
"This helped quite a bit," says Harmon.
The other benefit of involving the medical staff from the get-go: They would be able to hear about change from one of their own.
"It helps to hear it from their peers. Get someone young and ambitious who works well with other physicians," says Harmon. "They know that ultimately what we're teaching them here will reflect back on their clinics as well."
The next step was talking it over with the physicians.
"After developing the new policy, we took the whole plan back to the medical staff," says Harmon.
Any time large-scale change must run the gauntlet of the medical staff, hospitals know there will be a period of adjustment.
"They know they're going to have to change their outlook," says Harmon. "They are looking at us to give them the guidelines so they don't get in trouble with Medicare or Medicaid, all the powers that regulate if we get paid."
And, ultimately, all professionals want the best for their patients. In this case, patient care and financial requirements go hand in hand.
The new attitude Fredonia urged its medical staff to take? "Think in ink."
"We preach it all the time," says Harmon. "If you have a reason this person with normal blood values should be kept, write it down. We can't know a few years down the road what you were thinking when you made this call." Many times this will prevent a denial, she adds.
At first the physicians were resistant; some felt as though they were being told how to practice medicine. Now, however, they will call Harmon's office and run a process by her and her team. Physicians will explain what they're seeing and the process they want to follow, then ask for suggestions.
Following changes
Fredonia is part of the Great Plains Health Alliance, so it was constantly kept in the loop on utilization review updates from regulatory bodies. It also had access to resources to compare and contrast its existing policy with others.
"We pretty much knew what we had to do and how to get there," says Harmon.
The process of realigning the new policy took several months, however.
"The biggest thing is to stay on top of what [the field] is saying about [recovery audit contractors] and denials," says Harmon. "That changes what you're looking at and what you're thinking. All the time they're coming out with additional changes and updates."
Staying on top of CMS updates is the real key, though. "Get on their mailing list and be aware," she says. "It changes. What we put in our current policy is good, but things change."
Remember to look ahead. The sooner you trail behind the latest developments, the sooner your policy loses effectiveness. Don't be afraid to seek out seminars, online courses, or broadcast events to stay up to speed with the latest utilization review changes.
Little things can add up. For example, Fredonia found that notices providing opportunities to appeal denied claims were being included in remittance advices.
"They were making adjustments to our remittance advices, and at first we didn't catch it," says Harmon. "They weren't actually denying the whole account or stay, but they were looking at it and denying little things—if we charged for three IVs but only charted two [in error]. These weren't big-dollar issues, but when we went back through our remittance advices we found a number of them we weren't even aware of!"
It also helps to be in the loop with the right electronic resources. CMS and its various updates are a good starting point; the American Hospital Association also tracks changes and has mailing lists. Often, state and local organizations follow utilization changes and can be an ongoing resource for updates.
Finally, the right social networking tool can be a good way to reach out to fellow professionals for advice and to swap ideas.
In the end, the full backing of the board made development and implementation of Fredonia's policy a much more effective process. "We have an awesome board, and they listen to what we suggest. If we say it's important, they will back us up. We're fortunate," says Harmon. "Ultimately you could lose your Medicare certification if you don't do this right."
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This article was adapted from one that originally appeared in the October 2010 issue of Briefings on The Joint Commission [http://www.hcmarketplace.com/prod-16/Briefings-on-The-Joint-Commission.html], an HCPro publication.