[Enter your text here]
 
UTILIZATION MANAGEMENT PROGRAM
 
 
 
 
 
 
 
 
 
 
 
 
 
BETTY ABEL, RN
UM Coordinator
 
Spectrum begins its review process with  Pre-Admission Review for medical   necessity of planned, elective hospital   admissions, including psych/substance  abuse review.  During Pre-   Admission   Review, SRS begins the   process  of   Early Discharge Planning, and   identification of potential  Medical   Case  Management, Chronic Disease   Management, High Risk Pregnancy, and   PPO  steerage.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  Debbie Mikus, LVN - UM & Medical Case Manaager
 
 
Concurrent Management 
Spectrum deals with Admission Validation and Continued Stay Review, verifying admissions dates, diagnoses and continued stay treatment plans.
 
Spectrum Coordinators perform Continued Stay Review through regular contact with the hospital utilization review department and attending physician to obtain updates on the patient's progress, treatment and discharge plans.
 
Outpatient Surgery Notification 
Spectrum Coordinators review selected outpatient surgical procedures to determine medical necessity. In addition, these same selected procedures, if requested to be done as an inpatient, are reviewed to determine if they can be safely done as an outpatient, thus avoiding an unnecessary hospital stay.
 
Second Surgical Opinion Waiver Program (SSO) 
When combined with SRS’s Pre-Admission Certification and/or Outpatient Surgical Procedure Review, Second Surgical Opinions are requested when there is a question of medical necessity for the procedure. Otherwise, the need for SSO is waived.
 
Discharge Planning 
An integral part of the admission process, Discharge Planning is limited to diagnoses and procedures identified by SRS Coordinators as exhibiting the potential for discharge planning. SRS Coordinators communicate directly with attending physicians and the hospital discharge planning staff to clearly evaluate alternatives to hospitalization and their applicability.
 
Retrospective Review 
As requested by Benefits Plan Administrators, SRS will perform retrospective reviews on both Pre-Certified and non-certified stays when deemed appropriate.
 
Psychiatric and Substance Abuse Review 
Review of Psychiatric and Substance Abuse cases begins with psychiatric hospital pre-certification, with the Review Coordinator applying problem-specific criteria. Requests meeting the criteria are given a review checkpoint. Cases not meeting admission standards are referred to SRS’s Peer Review Panel.
 
A second validation of admission is  reviewed concurrently using severity  criteria and diagnosis-specific criteria.  As with other SRS reviews, this  methodology encourages discharge  planning or transfer of the care site.  Upon being certified for treatment of  alcohol or drug abuse, cases are  reviewed concurrently.
 
The SRS Review Coordinator gathers appropriate documentation from the attending psychiatrist. The coordinator evaluates the inpatient treatment plan using SRS criteria as the basis. The coordinator stays abreast of the patient’s progress throughout the treatment process by reviewing evidence of treatment and interventions and tracking improvement.
 
Later in the patient’s treatment, SRS severity and diagnosis-specific criteria are applied to the protocol when there is consideration for the patient’s transfer to another institution or an intensive outpatient program. The criteria are tailored to recognize stressors that may contribute to ongoing substance abuse in the patient. Special attention to these types of case details give SRS the ability to factor in stressors appropriately reducing admissions in some cases.
 
Reconsideration and Appeal Process 
If the initial review of a hospitalization or outpatient surgical procedure results in a negative determination after discussion with the patient's attending physician and SRS Physician Peer Review Panel member, all parties concerned are notified of their right to a reconsideration/appeal of the initial negative determination.
 
Requests for a reconsideration/appeal can come from the patient, attending physician or hospital/facility following receipt of the letter of negative determination. An unbiased second physician of the same specialty not previously involved in the case will review the initial determination and render a final decision in regard to medical necessity.
 
Service Hours 
Spectrum’s hours of operation are from 7:30 AM to 5:30 PM Monday through Friday, Central Standard Time (CST). The SRS’s main toll-free number is 1-800-258-5055 and locally (281) 419-6852
 
Confidentiality 
Patient confidentiality is an integral part of all health-care management. SRS follows all state and Federal regulations, such as HIPAA confidentialty requirements.
 
Copyright © 2014, Spectrum Review Services, Inc.  All Rights Reserved
 
 

email me