Utilization Review: Understanding Admission Status (NA1785)
Author(s): Patsy Barnes, RN, BA
Pre-Approved for: ACM, CA BRN, CCM, CE Broker Provider, Delaware BON, RNs
Credit Hours: 4
This course is online. All course material is available online and is accessible immediately after purchase from your account homepage. Certificate of Completion is available immediately upon passing the exam.
In this course, we will discuss admission to acute care hospitals, in particular the differences between an “observation” and “inpatient” status. Included are the utilization review requirements for facilities according to the Center for Medicare and Medicaid (CMS). The criteria for both admission statuses will be explained and the two principal means of addressing the criteria presented. The conversation has consequences for facilities, physicians, and patients as admission status has a major impact on payment for services rendered - a full understanding is critical. We will also include a section that discusses palliative care as a reasonable alternative to hospital admission for chronic, recurring disease. We will also address several government programs that help pay for caregivers for patients, including veterans.
- Define observation and inpatient status.
- Explain the articles of participation and the requirements for the utilization review process for admission, whether observation or inpatient.
- Explain the two-midnight rule and three-midnight rule.
- Describe the criteria for medical necessity and what entities define those criteria.
- List the consequences for facilities, physicians, and patients as a result of admission status.
- List the alternative choices to hospitalization for Medicare beneficiaries.
- Discuss how family members can be paid by the government to be caregivers.
- Explain the palliative care plan for patients.
- Overview of the problem
- Explanation of observation and inpatient criteria
- Conditions of participation and Medical necessity including the utilization review requirements
- Two midnight rule
- Three midnight rule
- What patients need to know
- Other alternatives to hospital admission
- The palliative care option