UTILIZATION MANAGEMENT PROGRAM
BETTY ABEL, RN
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
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.
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.
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.
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
Patient confidentiality is an integral part of all health-care management. SRS follows all state and Federal regulations, such as HIPAA confidentialty requirements.
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