Utilization Review

Utilization review represents a quality assurance function with the primary purpose to promote and assure the most efficient utilization of hospital services and facilities. In addition, identification of problems in health care practices, trending information, and working toward improvements are major utilization functions. Utilization review must be performed with discretion, fairness, and respect. Any and all reviews are done regardless of payment source to assure that the same standard is applied throughout the process. Often criteria are used to guide appropriate practice and to assure application is uniform. Reviews are conducted on a concurrent and, at times, on a retrospective basis. The most effective process is concurrent review for the admission and continued stay. During these activities, the underutilization and, in some cases, overutilization of services can be identified and corrected.

Criteria that are used need to be tested and validated for adequate utilization review. InterQual is a commonly used criteria set for the inpatient setting and outpatient setting. InterQual offers patient-specific criteria that encourages the reviewer to look at the severity of illness (SI) and the intensity of services (IS) as part of the review process. This proprietary company, McKesson, has a variety of other products to identify alternate level of care (ALC), length of stay (LOS), and precertification needs for procedures, durable medical equipment (DME), and imaging. This is a major source for substantiation for admission and continued stay and is used by many managed care companies as well as the peer review organizations (PROs).

Typically, the utilization review nurse is a registered nurse with three to five years clinical experience. This [Page 577]experience assists the nurse to review the medical record and speak to the attending physician with some knowledge of disease states and comorbid states. Certification for the utilization review nurse is an important credential. To be considered to take the exam, the nurse must have three years direct utilization review experience. Certification assures the expertise of the reviewer.

The medical record is the primary source for utilization review activities; however, conversations with the medical team may assist in completing the entire picture of what is happening with the patient on a given day. The physician and nurse are asked to document the care rendered, the plan of care anticipated, and the outcome(s) of the care given to support the need for both the admission and the continued stay. The old adage of “If it is not written, it is not done” is aptly applied in utilization review activities.

The utilization review activities assist the practitioner in making essential decisions not only about the need for the care but also in what setting the care should take place.

Data are usually collected about practices and are provided to the practitioner for consideration and action.