Utilization And Case Management At A Hospital

Sierra View District Hospital’s (SVDH) utilization review (UR) process originates in the Case Management (CM) department. They are responsible for the case review and obtaining social services for those patients in need of services. This paper will describe how this process works and how SVDH compares to another facility’s UR structure. There will also be a discussion about the weaknesses of the SVDH program.

Utilization Management at SVDH

The CM department is responsible for the UR process at SVDH. This department, which has 13 employees, is staffed as follows: four Case Managers; two licensed clinical social workers; four social services worker; a Department Analyst; and a Wound Care Specialist. An Administrative Director oversees the department.

The CM department follows a Utilization Review Plan (Appendix A) which establishes how the CM department will review cases and address potential discrepancies from established best practice guidelines like McKesson’s InterQual Criteria (McKesson, 2010). The four Case Managers are to conduct concurrent reviews on all Medicare admissions. They evaluate the patient chart and documentation to ensure the correct medical care status of “Inpatient” or “Observation Services” is assigned to the patient. If the patient is assigned the correct status then the Case Manager will flag the case for review in three to four days to ensure the status of the patient has not changed to such a degree that either a higher or lower service level is required. If that is the case, the manager will contact the primary care physician and seek an order changing the service level. If the physician does not agree, and the documentation in the case ceases to support the current level of care, the case manager will forward the case to the physician advisor for review. If the physician advisor agrees that a new level of care is called for then he/she will contact the physician to seek further clarification as to why the patient needs continued services at the current level. Depending on this conversation, there are four possible outcomes for the patient status. One, the patient status will remain at the current level of care because the initial physician has informed the physician advisor of extenuating circumstances regarding the case. Two, the physician will agree to the conversion of the patient status to either a higher or lower level of care. Three, the physician will not agree with the physician advisor, and the advisor will refer the case for the UR committee for a panel decision, which can overrule the original physician; or Four, the patient can be discharged from the hospital.

While Case Managers are working the UR of a patient, the Social Workers are concerned about any after-care the patient may require. The Case Managers and Social Workers work together to come up with a discharge plan beginning on the first day of admission. The Social Workers make sure the patients have all the contact information they may need once discharged, and the Case Managers work to ensure placement of the patient in an extended recovery care facility if needed.

SVDH’s UR Program Compared to Other Hospitals

SVDH’s UR program is comparable to that of Jewish Hospital (St. Louis). Prior to 1985, the Center for Medicare and Medicaid Services (CMS) reimbursed hospitals for services rendered. Due to increasing costs to the Medicare Trust Fund, the Diagnostic Related Group (DRG) system was developed to reimburse hospitals based on what the average cost of a particular surgery. UR programs at both hospitals began to change to meet the new challenges instituted by CMS. Utilization Review became Case Management at SVDH, while Jewish Hospital named their program Case Coordination. The staff members at both facilities became more involved in complete patient care, from admission to post-discharge. SVDH experienced the same growing pains that Jewish Hospital did when Observation Services became a new cost savings service line instituted by CMS.

The next challenge arose in 1990, when quality initiatives arose. These initiatives have only increased since that time, with the establishment of Quality Initiative Organizations (QIO). The QIOs review hospital data and report results back to CMS. The goal of these organizations is to locate services that do not meet their (CMS) standards. When found the QIO will deny payment for the services. While Jewish Hospital attempts to complete a 100% review for quality indicators on all cases, either concurrent or retrospective, SVDH chose to focus 100% on Core Measure cases only. While Jewish Hospital might be ensuring that all cases have a minimum standard of quality, SVDH complies with Joint Commission standards by only reviewing the Core Measure cases.

Weakness of the Program

There is a major weakness in the SVDH Case Management program, and it has been a weakness for some time. SVDH CM is not a 24/7/365 program. The Case Managers work Monday through Friday from eight to five. One Case Manager works from eight until noon on Saturday in the emergency room, but there is no coverage on Sunday. This means that the one Case Manager only reviews the cases that were admitted from Friday at 5:00 PM until 8:00 AM Saturday morning. If she has time she will also pick up any additional cases she can prior to leaving at noon, but there is no guarantee of that happening. The entire CM staff will review any cases not previously reviewed on Monday, if the patient is still in-house, or the case will undergo a retrospective review. This can cause continuing care problems for patients.

An example of one of these problems recently occurred when a patient was not reviewed due to no CM personnel on staff on Friday evenings. The patient presented to the Emergency Room on Friday, and was subsequently placed in “Observation Services” at the hospital, This case was not reviewed by the weekend case manager. On Monday morning, the CM personnel started reviewing the Medicare admissions and saw this patient on the CM list. In reviewing the chart, the patient plainly met “Inpatient” criteria. The attending physician could not be contacted so the case was referred to the physician advisor, who agreed the patient should have been classified as “Inpatient”. The status was changed as of Monday morning. CMS guidelines state that a status can only be changed upon the presentation of an order, and at no point can an “Observation Services” case be converted to an “Inpatient” status retroactively. The patient needed additional therapeutic services that would be provided in a long term care facility, but CMS guidelines state that Medicare will only pay for those services if the patient has had a “qualifying Inpatient stay in a hospital for a minimum of three calendar days” (Centers for Medicare & Medicaid Services, 2009). Since this patient’s status converted to “Inpatient” on Monday morning, the time spent in the hospital from Friday until conversion on Monday did not count towards the qualifying stay. The quandary then is to either discharge the patient to the care facility without a qualifying stay, thereby making the patient responsible for the entire cost of the care, or keeping the patient in the hospital for an additional two days in order to meet the qualifying stay requirements. The obvious answer is to keep the patient in order for them to obtain the necessary time to earn the qualifying stay. This, however, places a bed out of circulation that could have been used by another patient, and might incur costs that do not meet reimbursement criteria for the hospital. Had a CM staff member been on duty Friday night, the case could have been caught earlier, and the qualifying stay could have begun on Friday instead of Monday.

The major obstacle to hiring more Case Managers is, frankly, the cost of salaries. Any additional overhead costs are scrutinized closely in these times of shrinking reimbursements. Prior to bringing on new staff, in any area, the return on the investment is reviewed for a profitability margin. If a profit margin cannot be realized then the likelihood of incurring that additional expense is small. Other projects that bring a greater profitability margin have taken priority over additional staff in the CM department.


The CM Department administers SVDH’s UR program. The CM Department encompasses several different services, all dedicated to providing total care to the patient while in the hospital and post-discharge. SVDH’s program mirrors common practices within the industry. Like Jewish Hospital (St. Louis), CM at SVDH has evolved and changed over the years to meet the new demands placed on it by regulatory agencies. The CM Department constantly works with physicians to ensure patients receive the appropriate level of care based on physician documentation and InterQual guidelines. The major weakness in the CM program at SVDH is that it is not a 24/7/365 department. This flaw sometimes places the continuum of care for the patient at odds with the regulatory guidelines, and SVDH has to forego reimbursement for services in exchange for better overall patient care and patient financial security.

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