The Hospital Guide to Contemporary Utilization Review

The Hospital Guide to Contemporary Utilization Review 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.

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 his or her own hospital's UR processes
- Summarize the benefits of a dedicated UR team to promote compliance with the CoP
- Facilitate the development of a contemporary UR committee
- Assess an organization's opportunities to improve processes to benefit patient care and hospital success
- Recommend compliant language for the organization's UR plan
- Construct commercial contract language, in collaboration with the organization's contract manager, that promotes a partnership to ensure appropriate use of acute care resources
- Seek out operational resources to perform high-quality reviews that fully comply with the CoP - Explain the connection between a good utilization review plan and the hospital revenue cycle initiatives

Table of Contents

Chapter 1: History of Utilization Review
Chapter 2: The Regulatory Environment
Chapter 3: The Utilization Review Committee
Chapter 4: The Utilization Review Team and Its Partners
Chapter 5: The Utilization Review Process
Chapter 6: Tools, Training, and Resources for the Utilization Review Team
Chapter 7: Progression of Care
Chapter 8: Legal and Ethical Considerations

Who should read this book?

- Case managers
- UR coordinators
- UR committee members
- UR physician advisors
- Nurse managers
- Revenue cycle managers
- Compliance officers and auditors
- Healthcare lawyers and consultants