STANDARD 5: Utilization Review

5.1 Utilization Review Plan 

1. The healthcare organization must establish a process for utilization review. This process shall monitor, measure, and review the services provided to patients by the medical staff and other Licensed independent practitioners (LIP) both internal and external. Utilization review shall also include non-clinical support processes, facilities processes, outsourced processes, and any other internal or external factors influencing healthcare organization’s scope of resources. 

2. As per the requirement above, the Utilization Review Committee (UR) must be established. This Committee shall have two or more practitioners from the clinical staff, stakeholders such as representatives of the local community, and other service providers within the healthcare organization scope of services. The UR Committee process shall ensure that reviews are not conducted by individuals with a potential conflict of interest. 

3. The UR Committee shall identify and investigate variations in services to ensure that the variance is within the standard of care. 

4. This review shall occur at appropriate intervals as determined by the healthcare organization in order to efficiently achieve the intended purpose. Results of this review shall be reported to top management. Documented information shall be retained and maintained as required. 

5. The responsibilities and authority for those involved in utilization review activities in an UR Committee shall be described by the healthcare organization. 

NOTE 1 Variation in the use of healthcare organization resources can be the result of different work practices throughout the services provided. Appropriate supervision and analysis of consumed resources across the spectrum of services provided will highlight areas for service enhancement and drive continual improvement in quality and efficiency. 

  5.2 Scope and Frequency of Review 

1. Review shall address at least the following: 

a) review of the medical necessity of admissions; 

b) the appropriateness and necessity of the services ordered and provided with respect to diagnosis related groups or similar diseases processes including the associated medication management; 

c) extended stays beyond the expected average length of stay; 

d) that treatment plans reflect evidence-based care pathways; 

e) other processes associated with significant impact on available resources as determined by top management. 

2. In the case of patient related services, the review may be done before, at, or after, admission, the review may be done by sampling or other appropriate means. 

3. Before making a determination that an admission or continued stay is not medically necessary, the UR Committee shall consult the practitioner or practitioners responsible for the care of the patient and afford the practitioner(s) the opportunity to present their views. 

4. If the UR Committee decides that admission to or continued stay in the healthcare organization is not medically necessary, written notification shall be given no later than 2 days after the determination. This shall be addressed to the healthcare organization, the patient, and the practitioner(s) responsible for the care of the patient. 

5. If the attending practitioner does not respond or does not contest the findings of the UR Committee or those who performed the initial review, then the findings are final. 

6. If the attending physician does contest the UR Committee findings, and presents additional information relating to the patient’s need for extended stay, an additional physician member or ad hoc appointee of the UR Committee shall review the case. 

7. If this second review determines that the patient’s stay is not medically necessary or appropriate after considering all the evidence, their determination becomes final. Written notification of this decision shall be sent to the attending physician, patient, and Top management of the healthcare organization no later than 3 working days after the final decision. 

NOTE 1 3 working days shall be defined by the healthcare organization’s Top management. 

NOTE 2 In no case may a non-physician make a final determination that a patient’s stay is not medically necessary or appropriate.