Hospital Guide Contemporary Utilization
The Hospital Guide to Contemporary Utilization Review, Third 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 book covers a range of topics, including compliance with the UR Conditions of Participation (CoP), 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 UR program
- Describe the legal obligations of the hospital to comply with Chapter 42 CFR 482.30 of the 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 commercial payer 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