Admission or initial review
The
first evaluation of patient-specific psychosocial and/or clinical
circumstances resulting in hospitalization. The purpose of the
assessment is to ascertain whether the admission was medically necessary
and, if so, to determine the number of inpatient days that are medically
necessary based on the patient’s current signs, symptoms and treatment
plan.
When it is determined that the patient’s signs, symptoms and treatment plan are such that required services can be safely provided only in an acute inpatient setting, the hospitalization is certified as being medically necessary. If the admission is certified as medically necessary, the medical necessity of a specified number of days is also certified.
Adverse determination
A general term for any unfavorable outcome of utilization and quality review. Specific types of adverse determinations include medical necessity non-certification or denial, confirmed quality of care issue, and DRG change.
Only a physician may render an adverse determination, and there may be more than one type of adverse determination associated with a single hospitalization or review.
Attachments
A, B, C or D
HFS’ lists of ICD-9-CM codes or DRGs for which review is required. The lists have been included as attachments to notices issued by HFS to hospital providers.
CARES
(Crisis and Referral
Entry Services)
A component of an Illinois state-wide program implemented as a result of certain provisions of the Children’s Mental Health Act of 2003. The Act required that there be screening and assessment of children and adolescents status prior to any admission for acute care inpatient psychiatric services.
As explained by HFS in its June 17, 2004 Informational Notice to providers, the program is designed to:
1. Provide screening, assessment and treatment of any child who may be at risk of psychiatric hospitalization and who is eligible for public funding under any of three collaborating state departments.
2. Enhance access to coordinated community-based mental health services either in lieu of or following inpatient care.
3. Effectively link families and guardians to the appropriate levels of care.
The Informational Notice explains that there are two components to the program:
1. A Crisis and Referral system (CARES), and
2. Geographically dispersed screening agents (SASS providers).
Utilization review is not conducted for hospitalizations for which CARES or SASS involvement is not documented in HSI’s PURS data base.
Centers for Medicare and Medicaid Services (CMS)
A Federal agency that provides direction and technical guidance for the administration of the Federal effort to plan, develop, manage and evaluate health care financing programs and policies. For more information about CMS, please visit their Web site at www.cms.hhs.gov.
Certification determination
A utilization review outcome stating that health care services, including the need for hospitalization or for continuing acute inpatient days of care, are medically necessary.
Concurrent review
Although technically concurrent review is any review that is conducted while services are in progress, under the Illinois Department of Healthcare and Family Service’s (HFS’) acute care inpatient review program, the term is often used interchangeably with the term continued stay review.
Continued stay review
A sub-category of admission/concurrent review. An assessment of a patient’s current signs, symptoms and treatment plan performed when the admission review resulted in medical necessity certification for one or more acute care inpatient days and some number of days beyond the last date certified are deemed by the provider to be medically necessary.
The purpose of the review is to determine whether ongoing hospitalization is medically necessary and, if so, for how many additional days.
(DRG)
A classification system that groups patients according to certain characteristics including diagnosis, type of treatment, age, sex and the presence of complications or comorbidities. Each group is presumed to consist of hospital case types that are expected to require similar resource use.
DRG reimbursed hospitalization
An inpatient admission for which a pre-defined total fee is provided to a hospital when the admission is medically necessary and regardless of the patient’s total length of stay. The prospectively agreed upon fee is determined by the diagnosis related group (DRG) into which the admission is grouped after discharge. Considerations in determining the DRG include diagnoses, procedures, age, sex, and the presence of complications or comorbidities.
DRG validation
A process involving comparison of documentation in a medical record with the principal and all secondary diagnosis and procedure codes and patient discharge status code reported in a hospital’s reimbursement claim.
Hospitalization
An acute care inpatient confinement that is associated with and identifiable by a unique combination of a Medicaid recipient identification number (RIN), provider number, and admission date.
InterQual® criteria
A set of predetermined clinical indicators developed and approved by an established team of experts in the field of utilization review. The criteria are developed to be used by non-physician utilization review staff to determine whether, based on an individual patient’s signs, symptoms, and treatment plan, the proposed or current level of care is medically necessary.
Initial (admission) review
First evaluation of the patient-specific psychosocial and/or clinical circumstances resulting in hospitalization. (See “Admission or Initial Review”.)
Length of stay (LOS)
A period of inpatient confinement. A patient’s total length of stay is a mathematical function of the discharge date minus the admission date. The discharge date is not counted as a day of care. For example, a patient admitted on May 6 and discharged on May 10 incurs a four day LOS.
Medical necessity
non-certification
A determination by a physician reviewer that the health care services proposed or provided for a patient are not medically necessary or are not delivered at the appropriate level of care.
Per diem
A pre-determined all-inclusive and fixed reimbursement rate for health care services. For inpatient services, the per diem rate includes all services provided on a given day.
Physician reviewer or
Physician peer reviewer (PR)
HSI physician consultants who render medical necessity, quality of care and DRG coding accuracy determinations. The physicians are licensed by the state of Illinois to practice medicine in all its branches, engaged in active practice of medicine, board certified or board eligible in their specialties and have admitting privileges in an Illinois hospital.
Physician peer
review panel
A review committee comprised of at least three board-certified physician peer reviewers representing primary specialties and subspecialties as appropriate to the care under review. The panel renders the final determinations for serious quality issues, validates the presence of a pattern and requests a Quality improvement plan (QIP) if it determines that a serious quality issue or pattern exists. The panel also monitors the QIP for appropriateness and follow-through through progress reports.
Quality improvement plan
(QIP)
The documented and structured actions a hospital or physician is requested to establish and implement when a single serious quality issue is validated or when a pattern of lesser quality issues is confirmed.
Quality Improvement Organization
(QIO)
An organization that provides contracted services for the Centers for Medicare & Medicaid Services. QIOs work with consumers, physicians, hospitals and other caregivers to refine care delivery systems to ensure that Medicare and Medicaid patients receive the right care at the right time, particularly among underserved populations. The program also safeguards the integrity of the Medicare and Medicaid trust fund by ensuring payment is made only for medically necessary services. QIOs also investigate beneficiary complaints about quality of care.
Quality of care review
A comprehensive
quality review is conducted only when HealthSystems of Illinois (HSI)
has access to the complete medical record through retrospective
prepayment or post-payment review. Nurse reviewers apply the Centers for
Medicare & Medicaid Services’ Quality of Care Concern Categories; and if
a potential quality of care concern is identified, it is referred to a
physician peer reviewer.
A quality of care issue is only confirmed after a full chart review by a
physician peer reviewer is completed and the provider has been afforded
an opportunity to discuss or submit additional information. Serious
quality of care issues are reviewed by a physician review panel
consisting of at least three physicians.
Quality of care screening
As part of the admission/concurrent review process, nurse reviewers screen for potential quality issues based on the clinical information provided by the hospital. If a potential quality concern is identified, the nurse refers the information to a physician peer reviewer, and if the information suggests there is, or may be, immediate and significant risk to the patient, our physician reviewer will contact the attending physician to discuss the situation. In some cases, HSI may request that the hospital submit a medical record for post-payment review so that a complete quality of care review may be performed.
Reconsideration
A re-evaluation of a medical necessity non-certification (denial) determination. The re-evaluation is requested by the hospital or physician and is conducted by a physician reviewer who was not involved in the original adverse determination.
Retrospective
prepayment review (prepayment review)
A method of review that requires evaluation of a patient’s entire medical record and therefore is performed after the patient‘s discharge and before the hospital is reimbursed. In comparison to admission/concurrent (A/C) review, this method of review is more comprehensive and includes assessment of all of the following:
- Medical necessity of the admission and of the length of stay
- Appropriateness of invasive procedures
- Quality of care
- Accuracy of ICD-9-CM coding.
- Accuracy of DRG coding (for hospitalizations reimbursed on the basis of the billed DRG).
Retrospective
post-payment review (post-payment review)
A method of review that requires evaluation of a patient’s entire medical record and that is performed after the patient is discharged and after the hospital received reimbursement for the services.
Post-payment review is distinguished from prepayment review in that:
1. The individual outcomes or determinations do not influence the hospitals’ reimbursement.
2. Hospitalizations are selected for review from a sample of particular HFS-approved and pre-defined clinical categories. The clinical categories are subject to change.
Post-payment review includes evaluation of:
1. The medical necessity of the admission and length of stay.
2. The quality of care.
3. The accuracy of DRG coding.
4. For applicable records, the consistency of information provided during A/C review as compared to that documented in the medical record.
SASS (Screening,
Assessment and
Support Services)
An Illinois state-wide program implemented as a result of particular provisions in the Children’s Mental Health Act of 2003. The Act requires that there be screening and assessment of children and adolescents prior to any admission to a hospital for inpatient psychiatric services.
As explained by HFS in its June 17, 2004 Informational Notice to providers, the program is designed to:
1. Provide screening, assessment and treatment of any child who may be at risk of psychiatric hospitalization and who is eligible for public funding under any of three collaborating state departments.
2. Enhance access to coordinated community-based mental health services either in lieu of or following inpatient care.
3. Effectively link families and guardians to the appropriate levels of care.
The Informational Notice explains that there are two components to the program:
1. A Crisis and Referral system (CARES), and
2. Geographically dispersed screening agents (SASS providers).
SASS providers “perform screenings and authorize the SASS services.”
Utilization review is not conducted for hospitalizations for which CARES or SASS involvement is not documented in HSI’s PURS data base.
Utilization review coordinator
(URC)
An Illinois-licensed registered professional nurse with clinical experience and who has been trained in conducting utilization review, ICD-9-CM coding, DRG validation and quality of care screening and review.