Insurance Continuing Education - Inpatient Hospital Review

Treatment review can be either Prospective, Concurrent, or Retrospectively, as explained earlier. Review can be at any or all of these points in treatment.



Prospective Review. Pre-certification or pre-admission certification is probably the most recognized Managed Care technique as it is required by almost all plans, whether Managed Care or fee-for-service. It has proven that it prevents unnecessary inpatient hospital stays.



When a physician makes a recommendation for hospital treatment, the utilization reviewer is contacted, usually by the physicians. This contact is usually within 24-48 hours, except in case of emergency. The utilization reviewer is provided with the name of patient, name of doctor and hospital, diagnosis and proposed treatment and any other pertinent information. This information is matched against protocols developed for similar diagnosis and which indicates whether the treatment is proper for the diagnosis, whether it needs to be performed in a hospital or on an out-patient basis, and whether the proposed length of stay is in line with standards. If the treatment agrees with the protocols, the reviewer proves the plan and the patient are admitted to the hospital.



However, if the protocol doesn’t meet the proposed treatment, it is referred to a consulting physician who then contacts the patient’s doctor to discuss the situation and to see if they can agree on the treatment. Usually, they compromise on the treatment, or if not, the treatment could be disapproved and coverage denied.



Second Surgical Opinion. Second surgical opinion is also a very popular provision that requires that elective surgery be reviewed by another specialist prior to surgery. This requirement may be satisfied by simply getting the required second opinion, but some plans require that the second opinion agree with the first opinion. The costs of the second opinion are borne by the plan. Not all elective surgery requires a second opinion, as it is not cost effective them in many situations. Some surgeries are mandatory with all plans, such as hysterectomies or laminectomies.



Pre-admission Testing. Patients are tested prior to surgery by facilities outside of the hospital. This eliminates patients being admitted to the hospital a day or two early just for the tests. This is a popular requirement and is present on most plans.



Concurrent Review and Discharge Planning. As soon as the attending physician determines that a hospitalized patient is medically ready for discharge, discharge planning asses whether the patient needs continuing care could be performed at a lower cost with acceptable results, in another facility, such as a skilled nursing facility, nursing home, home health care, or rehabilitation services.



Retrospective Review. After the treatment has been rendered, it can be compared with established standards and guidelines. If the treatment doesn’t match the standards, payment can be denied. However, it is very rare that the payment is denied, but in most cases the information gathered in the review is used to educate the physicians and for date purposes in order to improve the review process.



Review of the Hospital Bill. The overpayment of hospital bills has received considerable publicity recently and a hospital bill review system more than pays for itself. Most overpayments are administrative errors, however some significant savings have been realized over deliberate overbilling. The hospital bill review determines, among other items, whether:



1. All services listed on the bill were actually performed,

2. Duplicate charges have been made,

3. Charges have been made for unauthorized procedures,

4. Charges are inconsistent with current medical practice,

5. Charges represent reasonable and customary frees, or conform to fee schedules,

6. The payers are responsible for a portion of charges, and which particular portions.



The bill review procedure can also determine whether the "codes" have been used correctly (called "code gaming").



Upcoding - erroneously coding simple procedures as more complex and expensive procedures.



Explosive - breaking down a group of laboratory tests performed on the same specimen into a number of separate tests, and billing separately for each charge.



Unbundling or "Fragmentation" - breaking down a complex procedure into separate and individual procedures and billing for each. Surgery, in particular, lends itself to fragmentation, as charges can be made for cutting, for suturing, etc.



Visit churning - refers to the physician billing for more visits than were performed.



Insurance Continuing Education

Continuing Education Insurance

Continuing Insurance Education