Q&A: Utilization Review Committee Membership

HCPRO Website, March 3, 2016

Q: My hospital is trying to ensure that our utilization review (UR) committee membership not only complies with CMS regulations but keeps up with the current UR environment. How can we ensure we have a well-rounded committee membership?

A: CMS’ Conditions of Participation (CoPs) for UR include specific requirements for the composition of the UR committee, specifying that it must be composed of at least two doctors of medicine or osteopathy. The presence of two or more practitioners is an important component of the UR committee structure for several reasons. First, reviews may not be conducted by any individual who has a direct financial interest in that hospital or was professionally involved in the care of the patient whose case is being reviewed. A physician on the committee who cares for hospitalized patients would need another UR committee member to review his or her case. Second, determinations of the UR committee must be discussed with the practitioner responsible of the care of the patient. If that practitioner disagrees with the determination of the first UR committee physician, it must be reviewed by a second committee physician. Having at least two physician members on the UR committee allows these determinations to be made expeditiously when needed. Despite the two or more practitioners requirement, many small, rural hospitals are often hard pressed to find physicians willing to serve. In that case, a group outside the institution may be contracted as long as it has been approved by CMS as specified in 42 CFR 482.30.
Membership on the UR committee has expanded to address the full scope of committee responsibilities in small, medium, or large community hospitals, and especially in integrated delivery systems and academic medical centers. Because the UR committee is no longer simply looking at admission and continuing stay appropriateness, committee membership has expanded outside of representatives of the medical and surgical staff. Today, members often include:
  • The director of emergency services
  • The medical directors of laboratory and blood bank services, imaging, nuclear medicine, catheterization lab, and other hospital-sponsored programs that affect resource utilization provide input on issues of utilization and medical necessity
  • Representatives of the hospital’s nursing, case management, quality, and compliance leadership hold collective accountability for UR across their hospital departments
  • The hospital’s board of directors is the fiduciary of all the hospital’s resources and serves on behalf of the community
For more information about UR, see the book The Hospital Guide to Contemporary Utilization Review.

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