Table of Contents
What is hospital utilization review?
Utilization review is a method used to match the patient’s clinical picture and care interventions to evidence-based criteria such as MCG care guidelines. This criteria helps to guide the utilization review nurse in determining the appropriate care setting for all levels of services across the arc of patient care.
How is payment determined for a CAH?
However, CAH payments are based on each CAH’s costs and the share of those costs that are allocated to Medicare patients. CAHs receive cost based reimbursement for inpatient and outpatient services provided to Medicare patients (and Medicaid patients depending on policy of the state in which they are located).
What does a hospital utilization review nurse do?
Utilization review nurses perform frequent case reviews, check medical records, speak with patients and care providers regarding treatment, and respond to the plan of care. They also make recommendations regarding the appropriateness of care for identified diagnoses based on the research results for those conditions.
What is a CAH facility?
Critical access hospitals (CAHs) provide essential access to high-quality healthcare in rural communities. They represent more than 2/3 of all rural hospitals and are vital for ensuring the health of communities that may not have access to larger facilities.
What is the difference between critical access hospital and acute care hospital?
Acute Care Hospitals (ACH) are hospitals that provide short-term patient care, whereas Critical Access Hospitals (CAH) are small facilities that give limited outpatient and inpatient hospital services to people in rural areas. Acute care is being a patient in a Hospital rather than an Urgent Care center.
What is a Critical Access Hospital (CAH) survey?
The Critical Access Hospital (CAH) survey is conducted in accordance with the appropriate protocols and substantive requirements in the statute and regulations to determine whether a citation of non-compliance is appropriate.
What is an effective utilization review (UR) program?
An effective utilization review (UR) program can help a healthcare organization reduce denials and increase payments. U.S. hospitals are losing millions of dollars each year because of denials by health plans and government payers for acute care.
What are the challenges of the Ur process in hospitals?
Although every hospital has unique challenges, major breakdowns in the UR process tend to fall into the following five areas, which are explored in detail below: In U.S. hospitals, UR tends to report up through varyious departments and is frequently shuffled around as part of reorganizational shifts.
How far is a CAH from the nearest hospital?
Be located either more than 35-miles from the nearest hospital or CAH or more than 15 miles in areas with mountainous terrain or only secondary roads; OR prior to January 1, 2006, were certified as a CAH based on State designation as a “necessary provider” of health care services to residents in the area.