hile I knew I wanted to be a physician from middle school, working in Utilization Review (UR) was an opportunity I couldn’t pass up. I was looking for a chance to diversify my skillset, a new challenge of sorts, and utilization review was something completely new to learn. This challenging job has a huge learning curve and continues to present me with new ways to help my patients and peers.

What is Utilization Review (UR)? 

Utilization review, at the most basic definition, is making sure that each patient is receiving the most appropriate care in the most appropriate setting. Our team looks at patient encounters in the hospital. On a case-by-case basis, we look at details like:

• Is this patient receiving care in the right setting?
• What is the medical necessity of this hospital stay?
• Is this patient admitted under the correct bed status?
• Is the patient moving through this episode of care as expected?
• Are there delays that are keeping this patient here longer than anticipated?

Are they ready for discharge from the hospital? For example, if a patient comes into the ER, but they can’t go home because they don’t have an appropriate caregiver, they sometimes get admitted to the hospital. However, this isn’t really an appropriate use of a hospital bed because it is not a medical need. We work with case management to try to get that patient to the right level of care for them.

There’s a lot of gray area in utilization 

Currently, there are 16 UR nurses, of which about 10 works on any given day to cover all of the different units of the hospital. They spend their day going over each patient encounter, making sure each patient is admitted to the appropriate bed status. But it can be difficult to decide which status is most appropriate from the get-go.

One way we determine if a patient meets inpatient status vs. observation is the Two-Midnight rule. This rule from the Centers for Medicare & Medicaid Services (CMS) dictates that if a doctor believes that the patient is going to require two or more midnights of medically necessary hospital care, then they should admit that patient as an inpatient. If a patient just needs one midnight of hospital care, they should be admitted as observation.  If a patient is admitted under observation, and needs ongoing care past the first midnight, their bed status can then be changed to inpatient.

We also use InterQual criteria, which is an evidence-based screening tool based on various diagnoses to determine the appropriate level of care for a patient. However, 20 to 30% of patients don’t fit into these criteria well.

With different sets of rules for different payors, it’s easy to get into the weeds with utilization review. It can feel very frustrating to providers, but in the end, is important to make sure the hospital is receiving appropriate reimbursement for the care provided to the patient.

UR process pain points 

As we run UR procedures, we sometimes find discordance. Discordance happens when a provider admits a patient but doesn’t quite get the admission status correct. For instance, they might select inpatient, even though the patient is undergoing an outpatient elective surgery. The UR nurses and I work with providers to explain the rules and ensure they agree with what kind of admission status is correct for their patient. Specifically, for Medicare A and B patients, a process must be followed to change a patient’s status from Inpatient to Observation, called Condition Code 44, that requires provider concurrence.  Because providers are so busy with patient care, this process can seem intrusive.

Denials for inpatient level of care can also be a large headache for providers and for us. We work with providers to address inappropriate denials.  Our nurses can send reconsiderations or arrange peer to peers to help overturn these denials.  We have found that addressing denials concurrently, rather than waiting until the patient discharges to write a letter of appeal, is much more effective. 

When issues arise 

Fortunately, most UR issues can be solved with a quick clinical discussion. We need to understand what care patients require and how they are progressing through their treatment. This additional information from the provider can help us ensure that patients who qualify for inpatient level of care are appropriately billed as such.   We work to get this information through simple communications in Spok or Voalte to try and make it easier for providers to respond. We really don’t want to add to their busy workload. Ideally, we are able to get a quick turnaround to fix discordance.

Utilization review can be confusing and seem unnecessary to providers on the front lines of patient care.  However, it is crucial to ensure that the hospital is billing insurance appropriately and receiving adequate reimbursement for the care that we provide.   

The UR RN Team and I are here to help guide you through these tedious processes!