Welcome to the third in a four-part series on CMS' expectations for utilization review (UR) in an acute care hospital. In this blog, we'll discuss the procedure for denial of stays. The Condition of Participation (COP) for Utilization Review at §482.30 form the basis for discussion.

In most hospitals, Case Managers monitor patients to determine if their continued stay as an inpatient is medically necessary. If a potential issue is identified, then communication with the patient's physician is usually enough to correct the situation. However, on those rare occasions where the patient's physician believes that the patient needs to remain in the hospital, then things can get a little tricky.

CMS requires that such cases be referred to the hospital's UR committee or subgroup thereof which contains at least one physician. If after reviewing the case, the committee agrees that the patient's stay is not medically necessary or appropriate, the attending physician must be notified, and allowed an opportunity to present his/her views and any additional information relating to the patient's needs for continued stay.

If the attending practitioner does not respond or does not contest the finding, then the finding is final.

If the attending physician contests the finding, then at least one additional physician member of the UR Committee must review the case. If both the first and second physician reviewer determine that the patient's stay is not medically necessary then that determination becomes final. In no case may a non-physician make a final determination that a patient's stay is not medically necessary or appropriate.

If the decision is that the patient's stay is no longer medically necessary, then the attending physician, patient (or next of kin), facility administrator, State agency (in the case of Medicaid) must be notified in writing no later than two days after the decision has been reached. If, the decision is that the patient's continued stay is justified, the attending physician must be notified and an appropriate date for subsequent extended stay review.

Lastly, remember that Medicare patients have the right to appeal a premature discharge (see Interpretive Guidelines for 42 CFR 482.13(a)). Regulations require coordination between the hospital's existing mechanisms for utilization review notice and referral to a Quality Improvement Organization (QIO) for Medicare beneficiary concerns. This requirement does not mandate that the hospital automatically refer each Medicare beneficiary's appeal to the QIO; however, the hospital must inform all beneficiaries of this right, and comply with his or her request if the beneficiary asks for QIO review.

QIO' are CMS contractors charged with reviewing the appropriateness and quality of care rendered to Medicare beneficiaries in the hospital setting. The QIO' are also tasked with reviewing utilization decisions. Part of this duty includes reviewing discontinuation of stay determinations based upon a beneficiary's request.

Join me in a couple of weeks for Part Four in this series as we look at how the Condition of Utilization Review is surveyed.

Rick's clinical background is in critical care nursing with a focus in cardiovascular and trauma service lines. He has held both clinical and executive management level positions in Quality, Risk, Education, Infection Control, and Regulatory Compliance.

Rick is a regular speaker at numerous state and national conferences on the federal regulations and accreditation standards, and is host of CIHQ's popular monthly webinars addressing key compliance challenges in today's environment.

Rick is nationally certified in healthcare accreditation, and serves as Chair of the Board of Examiners for the Healthcare Accreditation Certification Program (HACP). Rick has a degree in Nursing with a Master's Degree in Health Services Administration.