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dr-r-wuebkerTo prepare best for a potential audit from a host of Centers for Medicare & Medicaid Services (CMS) contractors, hospitals must ensure that their utilization review (UR) process is efficient and effective, and that utilization review staff are versed on Medicare conditions of participation (CoP) and other rules and regulations. It is critical that hospitals have a defensible and compliant medical necessity review process in place.

In order to achieve this goal, hospitals must establish and define each UR committee member’s role, then execute on those responsibilities. Properly designed, the UR committee can do more than just ensure appropriate hospital and professional service utilization; it can have a beneficial effect on quality of care and overall patient satisfaction. In order to achieve the highest level of compliance, the committee should be composed of several different groups within a hospital, as no one person has the insight to accomplish this alone.

Forming the Committee

The voting members in a UR committee should be physicians who have absolutely no conflict of interest. These physicians cannot have been involved professionally in the care of a patient whose case is being reviewed and can have no direct financial interest in the hospital. Non-physician health professionals and non-medical advisors are also important members of the committee. These members can include case management and administrative staff along with risk management personnel and the board of trustees. It also is highly recommended that executive leaders of the hospital such as the chief medical officer (CMO), chief nursing officer (CNO) and compliance officer stay involved as well.

Ensuring Compliance

Once all UR committee members are in place, it is the responsibility of this group to ensure that hospitals are compliant with government regulations regarding inpatient hospital services by conducting reviews of duration of stays and professional services. The committee must identify areas for improvement as well as best practices as they relate to medical necessity compliance. In order to be compliant with government regulations, a hospital must identify over- and under-utilization of extended stays, avoidable days, and quality issues.

The best way to scrutinize these areas of potential improvement is to screen and sample reviewed cases and compare the data to a larger sample group from similar hospitals.

Sample screening can be achieved in several different ways. A standard place to start is by examining a hospital’s quarterly Program for Evaluating Payment Patterns Electronic Report (PEPPER), which identifies outliers of services compared to similar hospitals. Government contractors use data like the information reflected in these reports when making a decision whether to audit.  The UR committee must strive for their PEPPERs to reflect their efforts to remain compliant with CMS.

The Committee at Work

Looking at past practices can help determine a course of action for the future. When cases arise, UR committees need to make quick, educated decisions regarding admissions or continued stay. A complete determination cannot be achieved simply by reviewing a chart, so members must consult with the physician or physicians responsible for the patient’s care. If the UR committee disagrees with a practitioner regarding the medical necessity of an admission, the committee can work with the physician to ensure that the patient is placed in the correct level of care. In some cases, even if the attending physician believes that an admission is valid, the committee may disagree and conclude that an inpatient admission is not medically necessary. Since decisions regarding medical necessity ultimately must be made by physicians, physician participation on the UR committee is a necessity in its own right.

The UR committee should meet on a regular basis – monthly meetings are a good starting point – with sub-groups meeting as needed to accomplish specific objectives. The timing of the meetings should be defined in the UR plan.

The key to managing a successful UR committee is to learn from others’ successes. The best practices presented in this article have produced positive results for hospitals across the country.  There is no way to prevent an audit, but there are many ways to prepare for one properly. The creation of an educated, dedicated and compliant UR committee is a great place to start.

About the Author

Ralph Wuebker, MD, currently serves as Vice President of Executive Health Resources’ (EHR) ACE (Audit, Compliance and Education) Team. This group of physicians conducts audits and regular visits to EHR’s client hospitals to provide ongoing education on a variety of topics including Medicare and Medicaid compliance and regulations, medical necessity, Recovery Audit Contractors, utilization review, denials management and length of stay.

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Creating and Executing Goals to Form an Effective UR Committee


Ralph Wuebker, MD, MBA

Dr. Ralph Wuebker serves as Chief Medical Officer of Executive Health Resources. In this role, Dr. Wuebker provides clinical leadership within the company and works closely with hospital leaders to ensure strong utilization review and compliance programs. Additionally, Dr. Wuebker oversees Executive Health Resources’ Client Services teams, who provide onsite education for physicians, case managers, and hospital administrative personnel and help hospitals identify potential compliance vulnerabilities through ongoing internal audit. An expert in CMS regulations, medical necessity compliance, utilization review, denials management, and program integrity efforts, Dr. Wuebker also serves as an industry thought leader and editorial advisor to the media, as well as a highly respected and distinguished industry speaker.

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