Utilization Plan

Hill Country Memorial Health System

Fredericksburg, Texas

Originating Department: Quality Management


TITLE:  Utilization Review Plan




EFFECTIVE DATE: December 21, 1998

REVISED DATE: February 7, 2002




 The Utilization Review objectives (established within the Medical Staff) are as follows:


A. To insure the maintenance of high quality patient care in the most cost effective manner.


B. To insure appropriate allocation of the hospital's resources addressing over-utilization, under-utilization and inefficient scheduling of resources.


C. To provide an educational program involving studies of patterns of care within the hospital, or on a regional or statewide basis.


D. To promote collaborative practice, coordination of care and continuity of patient care.


E. To review the hospital's discharge planning program and facilitate the achievement of expected patient outcomes and discharge within an appropriate length of stay.


F. To assist patients, practitioners, and hospital in assuring that hospital services and items for which payment may be made by Medicare, Medicaid, Champus and other patient populations are reasonable and medically necessary; and to assure that services provided on an inpatient basis could not, consistent with the provision of appropriate medical care, be effectively provided more economically on an outpatient basis or in a different type of facility.


G. To maintain liaison with and seek the assistance of other committees as indicated.


H. To assure that the approved Texas Medical Review Program denial and appeal procedures are followed in the performance of the program activities for Medicare, Medicaid and Champus patients within the hospital.




The Utilization Review (UR) Plan has been developed and approved by the Medical Staff and Administration.




Day Outlier  - exceeding the Average Length of Stay (ALOS) for a particular DRG.


Cost Outlier - charges exceeding the DRG reimbursement.


Case Management Type patients - patients with multiple medical conditions or complications that will require high utilization of resources.  Examples include: Two or more chronic diseases (DM, COPD, CHF, ESRD, etc.), end-stage cancer, frequent readmissions, serious impairment of ADL's, drug or alcohol abuse, ASA Class 4 or 5, and multiple procedures/surgeries.






A. The Utilization Management (UM) Physician Advisor will review:

  1. Case Management type patients referred by the Outcomes Coordinator.

  2. Day and Cost Outliers that are referred.  (Cases with a planned Swing Bed or discharge within 2 days of the ALOS will be excluded.)

  3. Unresolved cases of patients not meeting inpatient criteria.


B. Both physician and other professional personnel will perform the utilization review function.


C. Professional personnel representing other departments are included in a consultative capacity (Administrative, Nursing Service, Medical Records and Social Services).


D. The Texas Medical Foundation Review Program-Hospital Screening Criteria (and/or all supplements and revisions when published) will be used as the screening criteria to assess medical necessity and duration of stay of patients admitted to this facility.


E. No participants of Utilization Review have a financial interest in this hospital.


F. No physician advisor shall participate in the review of a case in which he/she is professionally involved in the care of the patient.


G. The hospital staff members conducting the non-physician reviews will be Registered Nurses serving as the Outcomes Coordinator (OC) and Discharge Planner.


H. All Utilization Review activities, including any findings and recommendations, will be confidential.  Patient names will not be used.

  1. Meetings:

  1. The Care Oversight Committee that meets bi-monthly will oversee the Utilization Review functions.

  2. A special meeting may be called by the UM Physician Advisor when necessary.


I. In the event that the UM Physician Advisor is unable to do reviews, the Chief of Staff will serve as the Physician Advisor or appoint one.




A. A Screening Review on surgical cases will be done as needed to determine the appropriate level of care prior to admission.


B. An Admission Review of every Medicare, Medicaid, Champus, and 5% of patients with other or no payment sources will be conducted to determine the medical necessity of admission.  The OC or the Discharge Planning Nurse will do the review within one working day (working day defined as Monday-Friday, excluding holidays) following admission.  If there is a problem regarding the appropriate status (inpatient vs. observation), the attending physician will be contacted a) to obtain additional information about the patient, b) to determine appropriateness of admission vs. observation, or c) to issue a non-coverage letter to the patient.  A referral will be sent to the UM Physician Advisor if the problem is unresolved.


C. Concurrent Reviews will be done on all Medicare, Medicaid, Champus, Swing Bed and randomly selected patients based on the patient's condition and treatment patterns.  (i.e. if total hip patients usually stay in acute care for 3 or 4 days before being transferred to an alternative level of care, reviews are not done unless they are in acute care for 4 or 5 days.)  The concurrent review will focus on those diagnoses, problems, procedures, and/or practitioners with identified or suspected utilization-related problems.  The concurrent review will look for delays in the provision of supportive services and will utilize the Medicare/Medicaid DRG length-of-stay as its guide for average length of stay.  Monitoring and identification of aberrant patterns of care including over and under-utilization of medical services as well as inefficient scheduling of resources will be done on a concurrent basis.  Focused areas such as case management patients and day and cost outliers, will be reviewed daily.  An anticipated length of stay (LOS) will be assigned and placed in the Progress note section of the chart within 3 days.  Updated DRG worksheets, which contain diagnoses, DRG information, and current charges, are placed in the back of the Discharge Planning section of the charts at the time of the review.  They are not a part of the medical record.


D. Utilization Issues on Extended Stay Patients:  In the event that:

  1. It appears a patient no longer needs acute hospital level of care, or

  2. Patient may be more appropriately cared for in another type of facility, or

  3. Potential cost outliers affect hospital resources, the Outcomes Coordinator will inform the Attending Physician and alternatives for provision of care required by the patient will be explored.  If the issue is not resolved, the UM Physician Advisor will be asked to review the case and give recommendations for the patient's care in writing.  Copies of the Physician Advisor's Recommendations will be sent to the physicians involved in the case and to the Outcomes Coordinator.  If recommendations by the UM Physician Advisor are not followed, the case will be referred to the Care Oversight Committee for resolution.  The Medicare and Texas Medical Foundation guidelines will be followed concerning hospital denials and Letters of Non-coverage.


E. Case Conferences will be held as needed and may include the Attending physician, the UM Physician Advisor, Outcomes Coordinator, Social Worker, Discharge Planner, the nurses caring for the patient and other staff as needed.  The patient and family will be involved if appropriate.  Plans for hospitalization, intermediate goals and discharge plans will be discussed.  Review of the plan, Medicare guidelines and alternative levels of care will be done with the patient and family as appropriate.  Case Conferences will be scheduled on cases reaching 15 days LOS.  (See policy on Patient Care Conferences.)


F. Discharge Planning will be initiated on a timely basis during hospitalization so as not to delay the patient's discharge.  The Discharge Planner who will work closely with Nursing Service, the physicians, the family and the Business Office will coordinate this activity.  Discharge planning will include placement in other facilities or referral to services that may be required to improve or maintain the patient's health status (i.e. Home Health Care, Hill Country Needs Council, etc.).  Each patient needing discharge planning will have an established and documented plan for discharge.  The Discharge Planning Meetings will be held at least twice weekly to assist in the identification of patient needs and in the continued evaluation and coordination of services by the multi-disciplinary team.  The team includes the physician, nursing, physical therapy, social services, Outcomes Coordinator, home health care as well as input from the admissions office, dietitian, cardiac rehabilitation nurse, respiratory therapy, speech therapy, occupational therapy, pharmacy and hospice.


G. Findings of related quality improvement activities and other documentation will be reviewed which affect appropriate utilization of hospital services.  The monitoring of the hospital's utilization of resources will be ongoing to identify problems and document the impact of corrective actions taken.




Medical care evaluation (MCE) studies will be performed to promote the most effective and efficient use of available health facilities and services consistent with patient needs and professionally recognized standards of health care.  MCE study topics that may be identified by the Texas Medical Foundation will be considered.  At least one study will be completed each year.  Follow-up to all studies will be conducted as required to ensure that recommendations have resulted in the improvement of areas found deficient.


Studies will emphasize identification and analysis of patterns of patient care and will suggest possible changes for maintaining consistent high quality patient care and effective and efficient use of services.  Each MCE study, whether medical or administrative, will involve physicians and will identify and analyze factors related to the patient care rendered in the facility.  Where indicated, the study will result in recommendations for change beneficial to patients, staff, the facility and the community.


Medical Records and other appropriate hospital data will be the sources through which data are to be obtained for each MEC study.  The results of each MCE study and how such results, where appropriate, have been used to institute changes to improve the quality of care and promote more effective and efficient use of facilities and services will be communicated and documented.




A. The Care Oversight Committee will oversee the Utilization Review functions and may include the following:

  1. Reports submitted by the Medical Records Department, other committees, administration, and others.

  2. Progress reports on any MCE study underway and the findings of completed MCE's.

  3. A review of hospital generated statistical information and patient profiles to identify conditions associated with excessive utilization, under-utilization, care identified as not being medically necessary, high cost, inefficient scheduling of resources.

  4. Actions taken regarding the admissions or continued stay of any patient reviewed and the reasons for the actions.

  5. Any plan and/or corrective action(s) recommended or taken as a result of MCE studies to correct deficiencies and improve medical care and hospital procedures.


B.  All UR records will be maintained by the OC and located in the OC office.


C. The minutes of the Care Oversight Committee are maintained in the Medical Staff office.


D. Records and reports will be available for review by the health-insuring agent, medical peer review contractor, Texas Department of Human Services (TDHS), and Department of Health and Human Services (TDHHS).


E. All UR reports, records and data will be maintained to assure confidentiality and to comply with all applicable regulations and requirements.




This plan may be amended with the approval of the Medical Staff and Administration.  The UR Plan will be reviewed every 2 years and revised to reflect the hospital's utilization review activities as needed.




Texas Medical Foundation Screening Criteria Manual

Medicaid Screening Criteria Manual

Medicare Hospital Manual




02/02 - To combine the UR Plan and Amendment and to reflect the utilization review activities regarding the change in the medical staff structure.