Assignment:

Write a minimum 500-word APA essay that describes the overall process problem being addressed with Denials in the Utilization Review department at the Hospital.

Within a process map, distinct shapes are used for different purposes; for example, a rectangle denotes a process, a diamond is used where a decision needs to be made, and arrows indicate movement from one step to another. Oval shape is used to illustrate the beginning and end of a process. Rectangular shape is considered a process box. This is the action that needs to be done at that step in the process, for example, collect data, analyze data, or use a form. The diamond demonstrates decision points. Multiple directions (yes/no) to illustrate distinct pathways based on which option occurs. Directional arrows help the user follow the flow of the process. It is helpful to keep the arrows going in the same directions as much as possible to simplify the map. A process box is a place where there are multiple steps that need to be further defined. Two kinds of process maps: Basic, cross-functional or swim lane format. Basic is simple, illustrates the decisions, starting and end points, and processes. It has a maximum number of steps with a limited number of options. Cross-functional or swim lane format have more than fifteen steps and/or a need for separate rows (swim lanes) for different disciplines or parallel activities. Examples are listed in the textbook on page 529, Figure 21.3 and page 532, Figure 21.6. For this assignment do not submit an organizational chart which is a process map but only identifies reporting structures and hierarchy. They demonstrate who reports to whom and do not have define steps.

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Process map

Figure 1. Utilization review process

Utilization review at the hospital can be divided into five phases: pre-admission, admission, concurrent, discharge, and post-discharge. The first phase is pre-admission that incorporates the activities that occur in the admission process (outpatient setting) before the patient is placed in the hospital bed in the inpatient setting. This includes all the activities that occur in the emergency department, patient registration and bedding process. The characteristics of this phase include review for patient classification either for observation or inpatient as incorrect classification could result in payment delay or denial so that valuable resources are consumed to rectify the situation. Also, screening for admission to hospital care versus alternate care is conducted as payors are likely to deny inpatient care that could be offered at a lower care level or care that inappropriately uses hospital resources while exposing patients to hospitalization risks. In addition, elective surgery review is conducted since incorrect classification could result in payors denying or delaying payment (Baker, 2016; Daniels & Hirsch, 2015; see Figure 1).  Utilization Review Process Discussion Paper

The second phase is admission that focuses on all the functions of critical case management. It includes the use of standardized inpatient utilization criteria to assign patients in appropriate classes, and admission review for medical necessity. The characteristics of this phase include early identification of discharge needs to prevent denials and avoidable inpatient days. Additionally, admission review of elective admissions is conducted to match changes in the condition of the patient following the procedure or surgery. Besides that, clinical review to payors for emergent/urgent admission is conducted to conform to payor contracts requiring clinical reviews at the time of admission (Baker, 2016; Daniels & Hirsch, 2015; see Figure 1).

The third phase is concurrent whereby the case manager performs a critical role in acting as communication conduits to link the community resources to providers, patient and family members, hospital health care team, and physicians. The managers review the clinical progress and status, document the case plan and intervention, identify barriers, and implement an action plan to address the barriers. The characteristic of this phase includes offering timely concurrent continued reviews as missed reviews could increase the probability of denials. Also, utilization management criteria are applied to identify unnecessary hospital days and inappropriate admissions (Baker, 2016; Daniels & Hirsch, 2015; see Figure 1).

The fourth phase is discharge whereby the discharge plan is executed with a focus on preventing readmission by applying a comprehensive plan that incorporates best practices. Also, review of authorized days is conducted to include an appeals process for inpatient days yet to be authorized (Baker, 2016; Daniels & Hirsch, 2015; see Figure 1).

The final phase is post-discharge that highlights activities for case management. It attends to payer requests for offering discharge and retrospective reviews as well as clinical information to help with authorization of inpatient days and post-billing denials. This is intended to improve physician and patient satisfaction, and decrease readmissions. The characteristic of this phase includes follow up with skilled nursing facilities as an established best practice that has implications for readmissions. Another characteristic is follow up with discharge plans to include durable medical equipment and home care. Yet another characteristic is active management of denials, and timely response to outstanding reviews and post-billing denials. It acknowledges that post-billing denials cannot be eliminated entirely thus necessitating an appeals program (Baker, 2016; Daniels & Hirsch, 2015; see Figure 1).

References

Baker, K. (2016). Patient Status Training Toolkit for Utilization Review. HCPro.

Daniels, S. & Hirsch, R. (2015). The Hospital Guide to Contemporary Utilization Review. HCPro.  Utilization Review Process Discussion Paper