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Utilization Review

Across
Working together
Evaluation of the appropriateness of the medical treatment and of the efficiency of healthcare services, procedures, and resources
Require 3 Inpatient nights,receiving medically necessary care
Components of utlization review-preauthorization, concurrent, and retrospective
Apply to Medicare patient admission status changed from Inpatient to Observation
The five rights
Indicia
Documentation of continuation of a service
Medically necessary care in hospital that crosses 1 midnight or less than 24 hours stay = Outpatient and ?
Down
Performed after care or service is provided
Pre-admission Review
Medicare part B pay Observation
Admissions: DX with MI, Heart Failure, Pneumonia, COPD Exacerbation, Hip/knee replacements
Retrospective
Medically necessary care in hospital that crosses Two midnight or more
Sufficent information will avoid Denials
The impossible can become the ?