Book Description

The Hospital Guide to Contemporary Utilization Review, Third Edition, is a comprehensive resource designed to identify utilization review (UR) best practices and provide guidance on developing and enhancing a contemporary UR committee. This book focuses on the latest UR and patient status requirements to help hospitals perform high-quality reviews and comply with regulations in a value-based world. The book covers a range of topics, including compliance with the UR Conditions of Participation (CoP), legal obligations of a hospital, contract language, and compliant UR plan language, to provide an understanding of the expectations of a UR program. Tips for intradepartmental collaboration are included to guide professionals through the process of selecting a physician advisor and partnering with nurses, case managers, and revenue cycle team members. This book will help you do the following: Identify the components of a best-practice hospital UR program Describe the legal obligations of the hospital to comply with Chapter 42 CFR 482.30 of the CoP Use the publication as a tool to assess your own hospital's UR processes Summarize the benefits of a dedicated UR team to promote compliance with the CoP Differentiate between traditional Medicare and Medicare Advantage Facilitate the development of a contemporary UR committee Discuss the pros and cons of the possible reporting structures for UR activities Examine the role of the physician advisor as a member of the UR team Recognize the crucial role of revenue cycle in the work of the UR specialist Recommend compliant language for your organization's UR plan Describe the components of the revenue cycle pertinent to UR Differentiate inpatient and outpatient payment rules Explain the basics of claim preparation Review physician billing and payment rules Differentiate between national coverage determinations, local coverage determinations, and commercial payer criteria Seek out operational resources to perform high-quality reviews that fully comply with the CoP Explain the connection between a good UR plan and a hospital's revenue cycle initiatives