Case Management

Sneak peek: Whip your UR committee into shape

Case Management Weekly, August 15, 2012

If your utilization review (UR) committee is like many others nationwide, it may not have actually met in years, and chances are your UR committee members are secretly glad that's the case. Let's face it; those meetings can be a complete snooze. 

Maintaining a strong UR committee is good business practice, said Deborah K. Hale, CCS, CCDS, president and CEO of Administrative Consultant Service, LLC, in Shawnee, Okla. It's also mandatory- Medicare's Conditions of Participation require facilities to create and maintain a UR committee, said Beverly Cunningham, MS, RN, vice president of clinical performance improvement at Medical City Dallas Hospital in Texas. 

Many organizations allow their UR committees to languish because they are not a Joint Commission requirement. State inspectors ensure that hospitals have UR committees, but these inspections occur only once every few years in some states, said Hale. 

Regardless, hospitals should not ignore the UR committee requirement. A strong committee facilitates the delivery of high-quality and cost effective care. It's time to shed the model of the past and restructure the UR committee so it can become a vital part of your organization. 

CMS requirements for UR committees differ slightly depending on whether an organization is a prospectively paid hospital or a critical access hospital, said Hale. 

Organizations that don't delegate UR reviews to an internal hospital committee can delegate them to one of the following, all of which must comply with CMS standards: 

  • An external group that performs the review on a contract basis
  • A local medical society or hospital group
  • A Quality Improvement Organization 

Editor’s note: This article is adapted from an article in the August Case Management Monthly published by HCPro, Inc.

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