Compliance with the Medicare Act will require that utilization review plan have two mechanisms: One mechanism is for "live" or "on the spot" review of the medical necessity for inpatient services during a continuous period of extended duration. This review must be done on certain days specified by Medicare regulations. I suggest that this be called medical necessity determination. The second mechanism serves for retrospective review of admissions, duration of stay, and professional services furnished (including drugs and biologicals), with regard to their medical necessity and the efficient use of facilities and services. I suggest that this be called utilization evaluation.
It will be necessary to handle these two problems by two separate methods. Medical necessity determination will require:
Adopting (a) definition (s) of a long-stay case.
Tagging each admission while in the hospital as a member of a "class" to determine when extended stay begins.
Slee VN. Information Systems and Measurement Tools. JAMA. 1966;196(12):1063–1065. doi:10.1001/jama.1966.03100250073025
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