| If the criteria for medical necessity is met, the admission is approved
and a length of stay assigned. If there are questions regarding
the necessity of the admission or requested days, the nurse reviewer
refers the case to a physician reviewer for further determination.
Alternative and cost-effective settings are discussed with the treating
physician. The bottom-line result is a reduction in the number of
hospital admissions and excessive lengths of stay without a decrease
in the quality of care.
The Process
The treating physician recommends admission for an elective procedure.
The patient or family member informs the doctor that the admission
must be pre-certified. The physician can pre-certify admissions
by contacting the Medical Review Nurse by telephone.
Emergency admissions must be called in by the patient's family,
the hospital, or physician within 24 hours of the admission or the
next business day following a weekend admission. The Medical Review
Specialist (always a Registered Nurse) evaluates the data against
established medical criteria to assess the medical necessity of
admission and the appropriateness of the treatment plan.
The Medical Review Specialist reviews the medical information specifically
for the following items:
- Is treatment customary for the diagnosis?
- Does the proposed treatment plan require an admission to an
acute care hospital?
- Are there alternative, more cost-effective treatment
settings where the proposed treatment plan could be performed?
(Doctor's office, Ambulatory Surgical Center or Outpatient
Unit of the hospital.)
The admission is certified if the information meets the established
medical criteria and the plan document.
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The Medical Review Specialists utilize Milliman Care Guidelines
(nationally accepted medical criteria) when screening cases
for intensity of service and severity of illness. Nationally
accepted length of stay norms are also applied when determining
medical necessity for continued stay in an acute care setting.
The Process
An initial length of stay is established at the time the admission
is certified. If the patient has not been discharged at the end
of this time period, the Medical Review Specialist then:
- Contacts the attending physician;
- Requests information on the patient's medical status and proposed
plan of treatment.
The Medical Review Specialist evaluates this information against
the medical criteria. A decision is made regarding the medical necessity
of the continued stay.
The Medical Review Specialist certifies the continued stay and
establishes a date for the next review, if the criteria are met,
then the Specialist:
- Contacts the attending physicians;
- Requests current status of the patient; and
- The potential discharge plans.
If the criteria are met, additional days are certified and a date
is set for the next review.
If the criteria are not met, the case is referred to a Physician
Advisor for review. This process can occur during the first or any
subsequent reviews. The Physician Advisor referral process proceeds
as in the pre-admission certification process.
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Whenever possible, a Medical Review Specialist will coordinate
and expedite the transfer of a patient to an alternative, more cost-effective
setting without decreasing the quality of care delivered. Discharge
planning begins upon admission to the hospital, so that all arrangements
can be made when inpatient stay is no longer medically necessary.
Cost savings to the plan can be realized through skillful foresight
and planning.
A Physician Advisor is utilized if the criteria for continued stay
are no longer met and the treating physician is either resistant
to discharge to an alternative setting or indicating no immediate
plans for discharge.
Intensive Discharge Planning
Occasions may arise where circumstances dictate immediate attention
from an experienced Case Manager to make alternative care recommendations
and begin implementation of these recommendations.
Examples might include:
- transfer of patient with spinal cord injury
- transfer of patient with severe burns
- arrangements for home I.V. therapies to avoid hospitalization
Managed Care Concepts, Inc. will confirm benefits with the claims
administrator and when indicated, discuss the case with the
employer contact person.
Retrospective Review
When there is a question as to the medical necessity of an admission
or additional unapproved days stayed, the file is referred after
discharge. Based upon the records provided, a panel of independent
board certified specialists will make a determination of the appropriateness
of care or the length of stay.
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