Hospital Guide to Contemporary Utilization Review, Second Edition

Quick Overview

The Hospital Guide to Contemporary Utilization Review, Second Edition is designed to identify UR best practices and provide guidance on developing and enhancing a contemporary UR committee.

Availability: In stock

Pubcode: HCCUR2
Price: $155

Hospital Guide to Contemporary Utilization Review, Second Edition

Stefani Daniels, RN, MSNA, ACM, CMAC
Ronald L. Hirsch, MD, FACP, CHCQM

The Hospital Guide to Contemporary Utilization Review, Second Edition, is a comprehensive resource designed to identify utilization review (UR) best practices and provide guidance on developing and enhancing a contemporary UR committee. This book focuses on the latest UR and patient status requirements to help hospitals perform high-quality reviews and comply with regulations in a value-based world. The second edition features extensive cover-to-cover updates with enhancements made to existing content and new chapters on the value of information and reporting as well as chapters on the intersection of revenue cycle functions pertinent to UR responsibilities.

The book covers a range of topics, including compliance with the UR Conditions of Participation, legal obligations of a hospital, contract language, and compliant UR plan language, to provide an understanding of the expectations of a UR program. Tips for intradepartmental collaboration are included to guide professionals through the process of selecting a physician advisor and partnering with nurses, case managers, and revenue cycle team members.

This book will help you do the following:

  • Identify the components of a best-practice hospital utilization review (UR) program
  • Describe the legal obligations of the hospital to comply with Chapter 42 CFR 482.30 of the Conditions of Participation (CoP)
  • Use the publication as a tool to assess your own hospital’s UR processes
  • Summarize the benefits of a dedicated UR team to promote compliance with the CoP
  • Differentiate between traditional Medicare and Medicare Advantage
  • Facilitate the development of a contemporary UR committee
  • Discuss the pros and cons of the possible reporting structures for UR activities
  • Examine the role of the physician advisor as a member of the UR team
  • Recognize the crucial role of revenue cycle in the work of the UR specialist
  • Recommend compliant language for your organization’s UR plan
  • Describe the components of the revenue cycle pertinent to UR
  • Differentiate inpatient and outpatient payment rules
  • Explain the basics of claim preparation
  • Review physician billing and payment rules
  • Differentiate between national coverage determinations, local coverage determinations, and SIM Plus™ criteria
  • Seek out operational resources to perform high-quality reviews that fully comply with the CoP
  • Explain the connection between a good UR plan and a hospital’s revenue cycle initiatives


About the Authors:

Stefani Daniels, RN, MSNA, ACM, CMAC, is founder and managing partner of Phoenix Medical Management in Pompano Beach, Florida. She is a member of the editorial boards of HCPro’s Case Management Monthly, Lippincott’s Professional Case Management journal, and the Case Management Society of America’s (CMSA) Today. She is the coauthor of the popular text The Leader’s Guide to Hospital Case Management and a contributing author to CMSA’s Core Curriculum for Case Managers, Second Edition. Daniels’ articles appear in many healthcare journals and magazines, and she is a popular speaker on contemporary care management at regional and national venues.

Ronald L. Hirsch, MD, FACP, CHCQM, is vice president of R1 RCM in the physician advisory services division in Chicago and a general internist and HIV specialist. Dr. Hirsch was the medical director of case management at Sherman Hospital in Elgin, Illinois. He is certified in healthcare quality and management by the American Board of Quality Assurance and Utilization Review Physicians. In addition, he is a member of the American Case Management Association, a member of the American College of Physician Advisors, and a fellow of the American College of Physicians


Page count: 150
Dimensions: 8.5x11
ISBN: 978-1-68308-714-4

What's New

The Hospital Guide to Contemporary Utilization Review, Second Edition, includes updated and new content on utilization review (UR) and the revenue cycle, billing, denials, new regulations including the requirements of the NOTICE Act, updated ABN information, and performance competencies. The new edition boasts updates to all the content you relied on with the first edition plus new sections on regulatory and reporting information. It features new chapters examining the intersection between UR and the revenue cycle as well as discussing the value of information with focus on over- and under-utilization as well as actionable data.

New sections and topics include the following:

  • Rationale for Hospital Utilization Review
  • Board Fiduciary Responsibilities and Resource Management
  • Agencies: RAC, MAC, ZPIC, QIO, OIG, CERT
  • Reports and Resources: PEPPER, MLN Connect
  • Transmittals
  • Requirements: IMM, MOON, ABN, HINN, Condition Code 44
  • Commercial Contracts
  • TPA Contracts
  • Time for Specialty Designation
  • Position Eligibility
  • Performance Competencies
  • Sharing Information With Care Coordination Partners
  • Physician Advisory Services
  • Utilization Review and the Revenue Cycle (DRGs, APCs, C-APCs, transfers, ACOs, bundled payments, value-based payments, rebilling)
  • The Value of Information (evidence-based protocols, over- and under-utilization, 835 remittance and remark codes)

Table of Contents

Chapter 1: The Origins and Evolution of Utilization Review

  • Introduction
  • Terminology: Is It Utilization Review or Utilization Management?
  • Rationale for Hospital Utilization Review
  • Board
  • Fiduciary Responsibilities and Resource Management


Chapter 2: The Regulatory Environment

  • Agencies: RAC, MAC, ZPIC, QIO, OIG, CERT
  • Reports and Resources: PEPPER, MLN Connect
  • Transmittals
  • Requirements: IMM, MOON, ABN, HINN, Condition Code 44
  • Commercial Contracts
  • TPA Contracts
  • Ethical and Legal Considerations


Chapter 3: Utilization Review Services

  • Time for Specialty Designation
  • Job Descriptions
  • Position Eligibility
  • Performance Competencies
  • Sharing Information with Care Coordination Partners
  • Physician Advisory Services


Chapter 4: The Utilization Review Process

  • Access Management
    • ED admissions
    • Financial clearance and authorizations
    • Transfers and direct admissions
    • Elective admissions
    • Inpatient, outpatient, and observation
    • 2-midnight rule
    • Short-stay exceptions
    • Criteria vs. medical documentation
  • Continuing Stay
    • GMLOS
    • Certification
    • Virtual utilization review vs. on-site
  • Utilization Review Documentation


Chapter 5: Utilization Review and the Revenue Cycle

  • How Hospitals Get Paid (DRG, APC, C-APC)
  • Transfer Payments (HHA, SNF, Other Hospital)
  • Methodologies
  • ACOs and Capitation
  • Insurance Matrix for the Utilization Review Specialists and Case Managers
  • Value-Based Payment Models
  • Claim Preparations
  • Revenue Integrity Teams


Chapter 6: The Utilization Review Committee

  • Background
  • Membership
  • Reporting Structure
  • Utilization Review Plan Content
  • Committee Agenda
  • Resource Management


Chapter 7: The Value of Information

  • Evidence-Based Protocols
  • Actionable Data
  • Margin Reports
  • Denials
  • PoCD/PAD
  • Readmissions
  • Utilization Review Outcomes


Chapter 8: Tools, Training, and Resources for the Utilization Review Team

  • MLN Connects 
  • Online Programs 
  • Transmittal Updates 
  • Utilization Review Sponsored Programs for Residents, Hospitalists, and Hospital Associates