Section 124.11. Utilization review.

 

(1)   Plan.

(a) Requirement. Every hospital shall have in operation a written utilization review plan designed to ensure that quality patient care is provided in the most appropriate, cost-effective manner. The utilization review program shall address potential over-utilization and under-utilization for all categories of patients, regardless of source of payment.

(b) Description of plan. The written utilization review plan shall include at least the following:

1. A delineation of the responsibilities and authority of persons involved in the performance of utilization review activities, including members of the medical staff, any utilization review committee, non-physician health care professionals, administrative personnel and, when applicable, any qualified outside organization contracting to perform review activities specified in the plan;

2. A conflict of interest policy stating that reviews may not be conducted by any person who has a proprietary interest in any hospital or by any person who was professionally involved in the care of the patient whose case is being reviewed;

3. A confidentiality policy applicable to all utilization review activities, including any findings and recommendations;

4. A description of the process by which the hospital identifies and resolves utilization-related problems, such as examining the appropriateness and medical necessity of admissions, continued stays and supportive services, as well as delays in the provision of supportive services. The following activities shall be incorporated into the process:

a. An analysis of profiles and patterns of care;

b. Feedback to the medical staff of the results of profile analysis;

c. Documentation of specific actions taken to correct aberrant practice patterns or other utilization review problems; and

d. Evaluation of the effectiveness of action taken;

5. The procedures for conducting review, including the time period within which the review is to be performed following admission and in assigning continued stay review dates; and

6. A mechanism for the provision of discharge planning required under s. DHS 124.05 (2) (j) .

(c) Responsibility for performance. The plan shall be approved by the medical staff, administration and governing body. The medical staff shall be responsible for performance of utilization review. The chief executive officer and hospital administrative staff shall ensure that the plan is effectively implemented.

(2)   Conduct of review.

(a) Written measurable criteria that have been approved by the medical staff shall be used in reviews.

(b) Non-physician health care professionals may participate in the development of review criteria for their professional fields and in the conduct of reviews of services provided by their peers.

(c) Determinations regarding the medical necessity and appropriateness of care provided shall be based upon information documented in the medical record.

(d) The attending physician shall be notified whenever it is determined that an admission or continued stay is not medically necessary, and shall be afforded the opportunity to present his or her views before a final determination is made. At least 2 physician reviewers shall concur on the determination when the attending physician disagrees.

(e) Written notice of any decision that an admission or continued stay is not medically necessary shall be given to the appropriate hospital department, the attending physician and the patient no later than 2 days after the determination.

(3)   Records and reporting. Records shall be kept of hospital utilization review activities and findings. Regular reports shall be made to the executive committee of the medical staff and to the governing body. Recommendations relevant to hospital operations and administration shall be reported to administration.

Cr. Register, January, 1988, No. 385 , eff. 2-1-88. Note: See the table of Appellate Court Citations for Wisconsin appellate cases citing s. HSS 124.11.