Utilization Review and Executive Health Resources Randy A. Rosen, MD EHR Medical Necessity Advisor Pam Ryan RN,BSN UR/CDI Director

Objectives By the end of the presentation, participants will be able to: Describe the role of Utilization Review and Executive Health Resources (EHR) in the acute care setting Describe EHR’s role at UK HealthCare Describe inpatient vs observation status principals Identify documentation expectations for new admission and continued hospital stay

Background Randy A. Rosen, MD MD, University of Miami      Internal Medicine/Nephrology training University of Alabama at Birmingham      Private practice Nephrology, 26 years      Medical necessity advisor for Optum/Executive Health Resources, 5 years     

Role of Executive Health Resources and Utilization Review Role of Utilization Review Insurance Authorization Denial Management Medicare Compliance Correct Billing Medicare Condition of Participation Role of Executive Health Resources History Observation/inpatient recommendations

What Does EHR Onsite Physician Do? Pilot project started in July 2015 Admission reviews Attending communication Peer to peer appeals with commercial insurance and managed medicaid Denial trends Peer to peer conversations Denial overturn rate

531 Peer to Peer Appeals, 304 Denials Overturned! Overturn Rate 57% 531 Peer to Peer Appeals, 304 Denials Overturned!

Observation vs Inpatient Define observation/inpatient Why is it important? How is the Medicare patient is affected?

Admission Documentation Use diagnoses rather than symptoms when feasible Use facts to support your case

Subsequent Days Documentation Reason why patient remains in the hospital should be clear