Utilization Management

As I noted in an earlier post, the current HUM 19, prescribing timeframes for concurrent review, fails to address situations where the patient or provider request an extension of a previously approved course of treatment in cases not involving urgent care.  URAC's proposed revisions to the HUM standards fail to propose any substantive change in this standard.  This is an easy fix, it seems to me, so I just now sent URAC this comment at its web page for submission of public comments on these standards:

URAC proposes no changes to the standard language of HUM 19.  I respectfully suggest that this is an appropriate time to address a gap in this standard. 
It currently reads as follows:
For concurrent review, the organization adheres to the following time frames: (Primary)
(a) For reductions or terminations in a previously approved course of treatment, the organization issues the determination early enough to allow the patient to request a review and receive a decision before the reduction or termination occurs; and (Primary)
(b) For requests to extend a current course of treatment, the organization issues the determination within: (Primary)
(i) 24 hours of the request for a utilization management determination, if it is a case involving urgent care and the request for extension was received at least 24 hours before the expiration of the currently certified period or treatments; or (Primary)
(ii) 72 hours of the request for a utilization management determination, if it is a case involving urgent care and the request for extension was received less than 24 hours before the expiration of the currently certified period or treatments. (Primary)

From my conversations with experienced reviewers, I believe this is, in fact, the way reviewers are addressing this issue already, and therefore would not involve a change in policy.

I do hope that the URAC Standards opportunity takes advantage of this opportunity to make an easy fix to a slightly broken standard.

The v. 4.1 upgrade to WC UM 34 is a partner to the revision to WC UM 33 (see blog on that standard here). Like the WC UM 33 revision, this is billed as a "clarification of intent" standard. Also like the UM 33 revision, it is a significant clarification.

The 4.0 version read:

Standard appeals are completed, and written notification of the appeal decision issued, within 30 calendar days of the receipt of the request for appeal. (Primary)

The question not answered by this standard was "to whom does the notification go?" But then, one would have thought that WC UM 35 answered the question. That standard reads, in relevant part:

For appeals determinations, the organization issues written notification of the adverse appeal decision to the patient and attending physician or other ordering provider or facility rendering service . . ..

But this deals only with affirmations of non-certifications -- what about the appeals that overturn the "non-certs"?

URAC sorts it all out in the v. 4.1 WC UM 34:

Standard appeals are completed, and written notification of the appeal decision issued, within 30 calendar days of the receipt of the request for appeal to the patient and attending physician or other ordering provider or facility rendering service. (Primary)

In other words, the written notice of the appeal decision, no matter which way the decision goes, must be sent to both the patient and the provider.

The original, v. 4.0 version of this standard reads as follows:

Upon request from the patient, attending physician, or other ordering provider or facility rendering service, the organization provides specific clinical review criteria upon which the non-certification was based. (Primary)

URAC, in v. 4.1, substitutes "clinical rationale" for "clinical review criteria", so that the standard now reads:

Upon request from the patient, attending physician, or other ordering provider or facility rendering service, the organization provides specific clinical rationale upon which the non-certification was based. (Primary)

It would help, it seems to me, to lay out the URAC definitions of these terms:

• Clinical Rationale
  • A statement that provides additional clarification of the clinical basis for a non-certification determination. The clinical rationale should relate the non-certification determination to the patient’s condition or treatment plan, and should supply a sufficient basis for a decision to pursue an appeal.
• Clinical Review Criteria
  • The written screens, decision rules, medical protocols, or guidelines used by the organization as an element in the evaluation of medical necessity and appropriateness of requested admissions, procedures, and services under the auspices of the applicable health benefits plan.

This is a significant change, at least on its face. The two terms describe distinctly different concepts, and it would appear that v. 4.1 gives the applicant more leeway than v. 4.0. However, we've noticed that at least some URAC reviewers have been interpreting this standard more liberally than the narrow term "Clinical Review Criteria" would suggest, so it may be simply that URAC is bringing the standard into alignment with what has been the practice of the reviewers.

The v. 5.1 upgrade to UM 34 is a partner to the revision to UM 33 (see blog on that standard here).  Like the UM 33 revision, this is billed as a "clarification of intent" standard.  Also like the UM 33 revision, it is a significant clarification.

The 5.0 version read:

Standard appeals are completed, and written notification of the appeal decision issued, within 30 calendar days of the receipt of the request for appeal. (Primary)

The question not answered by this standard was "to whom does the notification go?"  But then, one would have thought that UM 35 answered the question.  That standard reads, in relevant part:

For appeals determinations, the organization issues written notification of the adverse appeal decision to the patient and attending physician or other ordering provider or facility rendering service . . ..

But this deals only with affirmations of non-certifications -- what about the appeals that overturn the "non-certs"?  

URAC sorts it all out in the v. 5.1 UM 34:

Standard appeals are completed, and written notification of the appeal decision issued, within 30 calendar days of the receipt of the request for appeal to the patient and attending physician or other ordering provider or facility rendering service. (Primary)

In other words, the written notice of the appeal decision, no matter which way the decision goes, must be sent to both the patient and the provider.

The v. 5.1 "upgrade" for UM 33 is billed as a "clarification of intent", which sounds minor.  However, for some applicants, the "clarification" could be a bigger deal than might be suggested. 

The standard's purpose is to establish a time frame for notification of the patient and provider in the event of expedited appeals.  The previous version (v. 5.0) read:

Expedited appeals are completed with verbal notification of determination within 72 hours of the request followed by a written confirmation of the notification within 3 calendar days. (Primary)

What is unclear about this is to whom each of these two notifications, verbal within 72 hours and written within 3 days, must go.  Version 5.1 clears that up:

Expedited appeals are completed with verbal notification of determination to the requesting party within 72 hours of the request followed by a written confirmation of the notification within 3 calendar days to the patient and attending physician or other ordering provider or facility rendering service.  (Primary)

So, the 72-hour verbal notice need go only to the requesting party, whether it be the provider or the patient.  Only the written notification needs to go to both the consumer and the provider.  This surely will be a relief to those URAC applicants that were playing it safe and giving verbal notice to everybody in the first 72 hours.

Playing it safe with a standard like this is not a bad strategy: you don't mess around with mandatory standards. 

The original, v. 5.0 version of this standard reads as follows:

Upon request from the patient, attending physician, or other ordering provider or facility rendering service, the organization provides specific clinical review criteria upon which the non-certification was based. (Primary)

URAC, in v. 5.1, substitutes "clinical rationale" for "clinical review criteria", so that the standard now reads:

Upon request from the patient, attending physician, or other ordering provider or facility rendering service, the organization provides specific clinical rationale upon which the non-certification was based. (Primary)

It would help, it seems to me, to lay out the URAC definitions of these terms: 

• Clinical Rationale
  • A statement that provides additional clarification of the clinical basis for a non-certification determination. The clinical rationale should relate the non-certification determination to the patient’s condition or treatment plan, and should supply a sufficient basis for a decision to pursue an appeal.
• Clinical Review Criteria
  • The written screens, decision rules, medical protocols, or guidelines used by the organization as an element in the evaluation of medical necessity and appropriateness of requested admissions, procedures, and services under the auspices of the applicable health benefits plan.

This is a significant change, at least on its face.  The two terms describe distinctly different concepts, and it would appear that v. 5.1 gives the applicant more leeway than v. 5.0.  However, we've noticed that at least some URAC reviewers have been interpreting this standard more liberally than the narrow term "Clinical Review Criteria" would suggest, so it may be simply that URAC is bringing the standard into alignment with what has been the practice of the reviewers.  

Being a URAC reviewer myself for many years, I applaud such recognition of the wisdom of reviewers! 

So what are the mandatory standards?

URAC has always had mandatory standards. However, only with version 1.0 of the Core standards developed in the early part of this decade did the current notion of “mandatory standard” emerge. Mandatory standards typically, but do not always, have to do with consumer protection. A mandatory standard is any standard that has a weight of “5”.

In order to be fully accredited, an applicant must score at least 2 out of a possible 4 points on every mandatory standard. You can only get a score of two if you pass all of the “primary” elements of a standard. Therefore, what really is mandatory is that an applicant pass all of the primary elements of all of the mandatory standards.

The mandatory standards for the Health Utilization Management (v. 5.1) module are:

HUM - 9 - Pre-Review Screening Non-Certifications
HUM - 10 - Initial Clinical Reviewer Qualifications
HUM - 12 - Initial Clinical Reviewer Non-Certifications
HUM - 13 - Peer Clinical Review Cases
HUM - 14 - Peer Clinical Reviewer Qualifications
HUM - 22 - Written Notice of Non-Certification Decisions and Rationale
HUM - 30 - Non-Certification Appeals Process
HUM - 31 - Appeals Process
HUM - 32 - Appeal Peer Reviewer Qualifications
HUM - 33 - Expedited Appeals Process Timeframe

Naturally, an applicant for HUM also will have to meet all the mandatory standards for Core, v. 2.1, posted here. 

This standard, while easy to comply with, is not a slam dunk.  It provides:
The organization:

(a) Requires utilization management staff to identify themselves by name, title, and organization name; and

(b) Upon request, verbally informs patients; facility personnel; the attending physician and other ordering providers; and health professionals of specific utilization management requirements and procedures.

It carries a weight of only 3, and neither of its subsections is primary.  So, it is surely true to say that you can miss this all together and still have a great shot at accreditation.  However, since it is our theory as URAC consultants that we should leave no points on the table, is worth just a little extra staff training time to sweep up these readily available points.

The most common mistake that we have found relating to this standard happens when utilization management staff members identify themselves only by name and organization, omitting the job title.  This, obviously, is both easy to detect and easy to fix.

Less common, but perhaps slightly more difficult to address is the requirement of subsection (b).  A good way to diagnose problems with the standard is periodically to pose such requests to the members of your utilization management staff.  The question might sound like this: “imagine that I am a patient, and I want to know what the procedures are to get my procedure approved, and I want you to tell me in writing.  What are you going to send to me?” 

Obviously, this presumes that you have something easy to send to providers and patients that summarizes utilization management procedures and requirements.  If these procedures are embedded in a larger document that you do not want to send, I recommend that you have a ready supply of copies of that section of the document available for your staff members to send out to requesting providers and consumers.

UM 7 provides:

For initial screening, the organization limits use of non-clinical administrative staff to:

(a) Performance of “review of service requests” for completeness of information;

(b) Collection and transfer of non-clinical data;

(c) Acquisition of structured clinical data; and

(d) Activities that do not require evaluation or interpretation of clinical information.

The standard is weighted “4”, and subsections (a) and (d) are primary elements.

Important relevant defined terms include:

• Initial Screening.  Automated or semi-automated screening of requests for authorization that may include: (1) collection of structured clinical data (including diagnosis, diagnosis codes, procedures, procedure codes); (2) asking scripted clinical questions; (3) accepting responses to scripted clinical questions; and (4) taking specific action (certification and assignment of length of stay explicitly linked to each of the possible responses). It excludes: (1) applying clinical judgment or interpretation; (2) accepting unstructured clinical information; (3) deviating from script; (4) engaging in unscripted clinical dialogue; (5) asking clinical follow-up questions; and (6) issuing non-certifications.

• Nonclinical administrative staff.  Staff who do not meet the definition of health professional (including intake personnel).

• Health professional.  An individual who: (1) has undergone formal training in a health care field; (2) holds a license in a health care field issued by a state and the license allows the professional to practice within the scope of the license without the supervision of another licensed professional; (3) has professional experience in providing direct patient care; and (4) holds a post-secondary degree in health care. A postsecondary degree is defined as any college, university, or nursing school diploma obtained after graduating from high school (nursing diploma or associates, bachelors, masters, or doctorate degree). 

• License.  A license or permit (or equivalent) to practice medicine or a health profession that is (1) issued by a state regulatory body or jurisdiction in the United States; and (2) required for the performance of job functions.

• Review of service requests. Review of information submitted to the organization for health care services that do not need medical necessity certification nor result in a non-certification decision.

• Structured clinical data.  Clinical information that is precise and permits exact matching against explicit medical terms, diagnoses or procedure codes, or other explicit choices, without the need for interpretation.

This standard is the first of a trio of standards designed to set clear restrictions on the use of non-clinical personnel in the review process.  As the Program Guide notes, it applies to all review processes, regardless of the degree of automation, that do not involve clinical judgment and that do not result in non-certification determinations.

Documentation for desktop review includes a very clear policy and procedure that explicitly outlines the responsibilities of non-clinical review staff, their reporting relationships, and scope of work.  Job descriptions and organization charts are also useful documents for submission on AccreditNet.    It also is a good idea to submit sample scripts or algorithms for non-clinical review.

The on-site review will focus on interviews, demonstrations of any automated systems, and a review of sample scripts or algorithms.  More importantly, the URAC reviewer will be examining case files or evidence that the policy and procedure regarding non-clinical staff involvement is strictly followed.

Do not be misled by the fact that the standard is weighted “4”.  It is inextricably linked to UM 9, which is weighted “5” and is therefore a mandatory standard.  Problems with compliance with UM 7 likely will trigger noncompliance with UM 9, destroying any chance your organization has of attaining full accreditation.

UM 1 provides:

The organization utilizes explicit clinical review criteria or scripts that are:

(a) Developed with involvement from appropriate providers with current knowledge relevant to the criteria or scripts under review;

(b) Based on current clinical principles and processes;

(c) Evaluated at least annually and updated if necessary by:

(i) the organization itself; and

(ii) appropriate, actively practicing physicians and other providers with current knowledge relevant to the criteria or scripts under review, and;

(d) Approved by the medical director (or equivalent designate) or clinical director (or equivalent designate).

The standard is weighted "4", and all subsections are primary elements.

A standard covers both internally-developed clinical criteria and commercial criteria.  However, the key distinction is in the review and approval process described in subsections (c) and (d).  For internally developed clinical criteria, the process is quite clear: the organization and actively-practicing physicians must review the criteria which, in turn, also must be approved by the medical director or clinical director.

For commercial criteria, the standard is a bit different in application, if not in general requirement.  Most commercial vendors of criteria update those criteria annually.  This annual updating process generally takes care of the requirements of subsection (c).   Of course, the criteria still need to be approved by the medical director.  However, if the organization does not receive annual updates from the commercial vendor, it is still incumbent upon the organization to put the criteria through the annual review required by subsection (c), including a review by actively practicing physicians.

The documentation required to be submitted for desktop review is straightforward: a policy and procedure describing the development and approval of criteria along with sample pre-review scripts or clinical criteria.

The real test, however, will be during the on-site review.  It is during that stage of the accreditation process that the reviewer will be asking to see specific documentation of the review process for the criteria.  The Program Guide outlines the process:

·         Documentation indicating medical director or clinical director development and approval of clinical review criteria or scripts

·         Documentation indicating annual evaluation of clinical review criteria and scripts

·         Clinical case records illustrating initiation of the review process, pre-review screening, and initial clinical review, concurrent review and retrospective review.

What will be important for companies undergoing the reaccreditation process to remember is that the documentation of the clinical criteria review process must show annual review and approval.  It will not suffice for a three-year accredited company to show merely that it looked at the criteria recently.  Rather, documentation only to demonstrate the annual review required by this standard.