Revenue Cycle

Tip: Ask the right questions to ensure an effective admissions review program

Recovery Auditor Report, April 16, 2009

Are you certain your admissions review program is as effective as it needs to be so you can avoid errors that would result in denials in an audit? Robert Corrato, MD, MBA, founder, president, and CEO of Executive Health Resources suggests you ask the following pointed questions to ensure you keep your admissions review accountable:
  • Does your utilization review (UR) plan reflect a compliant process to meet the UR standards of the Conditions of Participation?
  • Is there valid and documented physician medical necessity decision-making occurring?
  • Are you following guidance put forth by CMS contractors?
  • Is the UR staff appropriately meeting its daily operational admission screening criteria accountabilities? Is the UR staff incorrectly applying or going outside of the strict application of screening criteria?
  • Is there ongoing education for UR staff in the use of screening criteria?
  • Is there inter-rater reliability testing and quality assurance (QA) of screening criteria review by UR staff?
  • Are UR screening criteria being applied to all Medicare beneficiaries in the hospital?
  • Are admission review results documented in an auditable fashion and placed within the patient chart?
  • Are secondary physician review determinations based upon the evaluation of regulatory guidance?
  • Is there communication between the physician making the secondary physician review determination and the treating physician?
  • Is there continuing education of physicians making secondary physician review determinations to ensure application of up-to-date clinical evidence and regulatory guidance?
  • Is there inter-rater reliability and QA testing of the secondary physician review?
  • Does the chart documentation reflect the secondary physician review determination and the process?
  • Is there a process to ensure that the physician order is consistent with the admission status determination?
  • Is there a process to ensure that the treating physician, hospital, and beneficiary are aware of final claim status before patient discharge?
Editor’s note: Robert Corrato, MD, MBA, is founder, president, and CEO of Executive Health Resources. This tip was adapted from “Monitor One-Day Stays Under RAC Scrutiny,” one of the many sessions presented at the Recovery Audit Contractor Defense Summit held in March. To listen to this presentation and others available from the RAC Defense Summit, visit HCMarketplace.

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