Tip: Advice for utilization-management audits
Compliance Monitor, May 12, 2004
Want to receive articles like this one in your inbox? Subscribe to Compliance Monitor!
When you audit your utilization management (UM) process and only focus on business aspects of your organization, you could be ignoring important controls that occur on the clinical side.
Utilization management (UM) programs help hospitals maintain appropriate lengths of stay and resource consumption, avoid submitting claims for services that are not medically necessary, limit excessive payment denials, and protect patients from unnecessary tests or procedures, says Jean Lambert, manager of internal audit services at Froedtert Hospital in Milwaukee.
Use these guidelines to build an effective UM audit:
1. Include clinically knowledgeable staff in this audit, Lambert says.
2. Consider reviewing the communication flow between the UM and managed-care contractors. Communication should be in real time.
3. Discuss with UM leaders which criteria they use to evaluate patients. Determine the following:
4. Make sure all individuals involved in the UM process understand the financial and clinical aspects of UM, says Debi Weatherford, director of internal audit and corporate compliance for Children's Healthcare of Atlanta.
Want to receive articles like this one in your inbox? Subscribe to Compliance Monitor!
Related Products
-
Strategies for Health Care Compliance
News and real-life examples to increase the effectiveness of your compliance program. Strategies for Health Care Compliance...
-
Compliance Monitor
This HTML e-mail newsletter delivers news on Medicare and Medicaid fraud and abuse, as well as recent documents and targets...
-
Medicare Weekly Update
Each issue of Medicare Weekly Update includes the latest CMS proposed and final rules, CMS manual revisions, and...
-
Medicare Update for Physician Services
Medicare Update for Physician Services is a free, monthly e-zine that delivers news and information to help physician...
Most Popular
- Articles
-
- Q/A: Volume requirement for reporting hydration services
- Featured blog post: Nurses face felony charges after reporting physician to the Texas Medical Board
- Catch up on what's new with injections and infusions
- Identify potential Medicaid RAC target areas
- HIPAA Q&A: Level of encryption needed for email
- Topic: CMS, OESS post new security compliance review information, checklist
- Capturing all necessary codes for IUD insertion and removal can be challenging
- What does case-mix index mean to you?
- OB services: Coding inside and outside of the package
- QA:Coding multiple initial infusions
- E-mailed
-
- Q/A: Volume requirement for reporting hydration services
- Featured blog post: Nurses face felony charges after reporting physician to the Texas Medical Board
- CMS has reformulated payments for some bilateral procedures
- HIPAA Q&A: Level of encryption needed for email
- Q&A: Follow CMS' coding guidelines when using modifier -25
- What does case-mix index mean to you?
- Catch up on what's new with injections and infusions
- New conflicts of interest create new challenges
- Q/A. One injection code or two?
- Cohesive History and Physical Requirements
- Searched