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

2. 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

3. 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   

4. 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

5. 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

6. 531 Peer to Peer Appeals, 304 Denials Overturned!
Overturn Rate 57%
531 Peer to Peer Appeals, 304 Denials Overturned!

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

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

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