Strategies for Creating a Valuable Utilization Review Committee

The federal statute 42 CFR § 482.30, in the Conditions of Participation for Utilization Review (CoP), requires that each hospital must have in effect a utilization review (UR) plan and a utilization review committee (URC). The CoP lists specifications regarding committee requirements; however, it is left up to the hospitals to decide how functional these committees will be.

Utilization Management versus Utilization Review

Utilization management (UM) is encompassed by processes and workflows put in place by hospital leadership to contain costs, improve operating efficiency, and enhance use of hospital resources. UR is a subset of UM, and refers to the tools and methodologies that hospitals and payors use to ensure that the appropriate level of care in the hospital is achieved for patients.

Regardless of what each hospital calls its UR committee (URC or UMC), the functions within this committee should address topics related to the utilization management of the hospital, and should be clearly stated in their UR plan. Utilization review will involve the day-to-day activities of UR specialists and physician advisors. These specialists will likely overlap with the URC, and will be called upon during the day to address requirements for Medicare and Medicaid beneficiaries, such as discharge appeals and Condition Code 44s. The aggregated data, plus more, will be discussed as part of the URC, as it applies to the UM strategy for the hospital.  

Meeting the Minimum Expectations

URC must consist of two or more practitioners who carry out the UR function for the hospital. They typically include leadership in UR and/or case management. In addition, there must be two members of the committee who are physicians, ideally directly impacted or involved with the UM interests of the organization. Typical individuals who fulfill this role are a hospital’s physician advisor, chief medical officer, medical director for hospitalist, and/or medical director for emergency physicians. The goal is to ensure that the members of the committee are interested and invested in the topics discussed, and can leverage other key stakeholders in the hospital, especially when reporting URC meeting updates to the medical executive committee. These two physicians must be part of the medical staff; however, there is no requirement that they be employed by the hospital.

It is also important to note that although the committee will be reviewing physician and departmental data and utilization practices, the committee holds no direct authority regarding performance issues. During a hospital survey by its accrediting body or during state review, the hospital will be expected to furnish their UR plan, UR committee meeting minutes, sample presentations, and evidence of meeting attendance, as well as follow-up actions to the topics discussed. The surveyors will be looking for congruency from what is in the plan to what is discussed in the URC (and acted upon in the committee). Surveyors will typically expect the URC to meet on at least a quarterly basis. The scope of CoP 482.30 defines that the URC is responsible for the management and review of hospital resources, including admission status, continued or outlier patient stays, and use of professional resources, so these items will need to be addressed specifically.

Making the Committee Meaningful

What the rules do not say:

• Who else is included in the URC as committee members. Such members could be leadership from nursing, surgery, emergency, bed placement, clinical documentation integrity (CDI), health information management (HIM), financial analysis, denials and appeals, revenue cycle, lab, pharmacy, and/or physical therapy. 
• What the topics discussed by the committee will be. The goal of the committee is to evaluate resource utilization of the organization. Examples are given regarding blood product usage and antimicrobial stewardship; however, the committee could also be reviewing such items as hospital deferrals, medical supply wastes, or unnecessary surgery cancellations. 
• How frequently the committee can choose to meet, and if the committee would want to have subcommittees, such as connecting the URC directly with a denials committee or patient complex case reviews (which could be optimal).
• Why topics are presented, and what format they are given. Engaging your audience means avoiding death by PowerPoint. Consider asking the leaders involved in the work to provide slides, and ensure that the slides are easy to understand and involve questions and topics for committee discussion. 

Consider reviewing with hospital leadership/c-suite the top priorities of the organization regarding resource utilization, and see how those can be addressed through the committee either directly or as a subcommittee that will report its findings. This will allow for greater c-suite engagement – and potentially more physician engagement. This will also ensure that these issues do not fall to another area, where leadership is forced to have “yet another meeting,” when it could all flow through the URC (the meeting that is required).

Topics to consider:

• Observation rate and length of stay (LOS; likely just the topic that will get the CFO to sit in and see what’s happening);
• Trends of concurrent and retroactive denials;
• Hospital diversions and ED holds;
• Cancelled surgeries due to lack of authorization;
• Throughput: progression of care delays;
• Outlier case reviews of extended stays and high costs (consider as a weekly subcommittee);
• Review of the Program for Evaluating Payment Patterns Electronic Report (PEPPER), which can be useful as it pertains to discussing outliers, and may give the team additional areas to focus on for improvement. If you don’t receive this, you can find information at https://pepper.cbrpepper.org/;
• Overutilization of services: imaging, lab, therapy;
• Antimicrobial stewardship/pharmacy;
• Avoidable day reports and action steps;
• Value-based metrics and hospital performance related to costs of care;
• Compliance concerns related to audits; and
• HIM, coding, and CDI performance.

Sample UR Committee

Given the potentially broad scope of work inherent to modern UM, the minimum requirements for the URC are arguably insufficient to address evolving healthcare system needs. Health systems are increasingly charged with ensuring the provision of value-based care, appropriate use of healthcare resources, and standardization of evidence-based treatments, while also maintaining revenue and compliance integrity. Healthcare customers are increasingly cost- and insurance-savvy, with expectations that their healthcare providers be effective custodians of their insurance benefits and bank accounts. As such, the traditional URC alone is just not enough in today’s complex healthcare ecosystem.

The regulatory and survey requirements for the URC are established, and the rules still need to be followed to the letter. However, structuring a modern and effective UM program dictates the need for a more robust arrangement of multiple committees that report their activities and outcomes to the URC. One approach, adopted at North Memorial Health Hospital in Robbinsdale, Minnesota, utilizes multiple committees charged with various aspects of URC requirements and effective UM practices. This approach has been an effective way to produce optimal outcomes. The following is a visual representation of that approach, followed by the descriptions and charges of those committees:

URC:

The committee charged with the traditional mandated activities, as outlined in the minimum requirements, with the addition of functioning as a steering committee for subcommittees. The URC can report through various leadership structures, including medical executive, quality, and clinical leadership.

Denials Prevention and Management (DPAM):

Primarily adjudicates contracted plan denials, including Medicare Advantage (MA) plans. This committee ensures that there is no single decision-making on self-denial or the decision not to appeal a case. If not overturned, all failed peer-to-peer cases are reviewed for decision on post-bill appeal. If the decision is to self-deny or accept denial, reason for acceptance is documented for reporting, trending, and tracking. This is an excellent venue for physician advisor and UM/RN education, led by the denials management RN coordinator. 

Readmission Prevention and Management (RPAM):

Addresses unique treatment plans for high-utilizers, reviews avoidable readmissions for quality improvement initiatives, and addresses readmission denials for potential appeal. It is led by the CM manager and supervisor.

Avoidable Nights Prevention and Management (APAM):

Reviews avoidable night reports, identifies trends, and establishes quality improvement initiatives that can be assigned to appropriate hospital committees for additional work. It is led by the UM manager.

Acute Care Medicine/Clinical Leadership Council (ACM/CLC):

Multidisciplinary committee that develops, implements, and tracks evidence-based clinical care pathways. It is resourced with data analysts, IT/EHR experts, provider champions, nursing, and other key stakeholders, and is led by the medical director for quality.

Standing members are part of all committees, including UM/CM RNs, UM/CM leadership, physician advisors, and the medical director for UM/CM. In addition, based on the committee charter and responsibilities, revenue cycle, clinical, and quality team members are assigned as permanent members. Interested members of the medical staff are also invited to participate.

Structuring the innumerable responsibilities of URC into subcommittees can allow for more effective outcomes by targeted participation of busy team members and leaders and the creation of multiple pathways to achieve optimal outcomes for patients and the health system. URCs do not need to be perfunctory meetings that only exist because they are mandated by the Centers for Medicare & Medicaid Services (CMS). They can be optimally designed to run and operate via creative means to manage and improve the usage of hospital and patient resources.

References:

42 CFR § 482.30 – Condition of participation: Utilization review. | Electronic Code of Federal Regulations (e-CFR) | US Law | LII / Legal Information Institute (cornell.edu)

Daniels S. & Hirsch R. (2021) The Hospital Guide to Contemporary Utilization Review, Third Edition. HCPro, Brentwood, TN.