While it’s true that managing the UM plan and serving on the utilization review committee are not viewed as exciting or glamorous, a solid plan provides the foundation for a meaningful, action-oriented initiative that can drive improvement and change.


1. Purpose (Scope):

Example: The UM plan provides an organized, collaborative, system-wide approach to resource management while maintaining quality of services and adhering to professionally recognized standards. The overarching principle outlined in the plan is to ensure that the hospital provides medically necessary, reimbursement-eligible services at the appropriate level of care while optimizing quality outcomes and financial performance. The plan describes methods for conducting reviews of the appropriateness and medical necessity of admissions, continued stays and supportive services while providing for a continuum of care services and discharge planning. Open communication and ongoing education on appropriate utilization practices are key components of the plan.


– Delineates the responsibilities and authority for those involved in the performance of internal and external utilization review;

– Establishes the protocols for review for medical necessity of admissions, extended stays, professional services and appropriateness of setting;

– Mandates the review of outlier cases based on extended length of stay and/or extraordinarily high costs; and

– Mandates the review of over-utilization, under-utilization and inefficient utilization of resources.


2. Goals and Objectives:




– To ensure effective and efficient utilization of hospital facilities and services with performance improvement achieved through a concurrent, collaborative process of utilization review of all hospital admission reviews, continued stay reviews and retrospective reviews, using firm criteria.


– To track and trend length of stay, issues with avoidable days, questionable use of resources and the cost-effectiveness of services provided.

– To systematically identify and respond to each patient’s need for continuing care planning before hospitalization or as soon as possible after admission.


– To assess the appropriateness of treatment settings, including the medical necessity of hospital admission and hospital continued stays, and to identify opportunities for providing quality care more economically in alternate care settings.

– To identify patterns of under-utilization, over-utilization, and inefficient use of resources; and to recommend and/or initiate actions to improve the use of healthcare services.


– To initiate and/or recommend improvement plans when areas of inappropriate utilization are identified, and to monitor the effectiveness of problem resolution strategies and improvement plans.


– To provide concurrent identification of and, where possible, appropriate intervention in, issues related to utilization of resources, risk management and quality of care.


– To promote continuity of care and services by identifying all patients in need of post-hospital care, ensuring that each has an appropriate, timely plan for discharge.


– To serve as an advocate for appropriate care, treatment and discharge decisions based on recognized standards of care and not solely on the reimbursement determinations of external review entities.


– To communicate utilization information and provide education on appropriate utilization of resources in a collaborative, collegial manner to individual practitioners, departments, committees, senior leadership, the medical staff and the governing board of the hospital.


The above examples are not all-inclusive, but are provided as a starting point. Each hospital should establish its own unique purpose (scope) and goals and objectives based on services provided, availability of data, resource availability and physician input. Next month the article focus will be on the authority and responsibility for a UM plan.


About the Author

Donna McLean, RN, MBA, CMAC, is president and co-founder of DSE Associates — Healthcare Case Management Solutions. Donna’s 25 years of firsthand experience in providing healthcare services qualifies her to understand the needs and requirements of clients in the healthcare arena.

Contact the Author

Comment on this Articleeditor@racmonitor.com

(§ 482.30 Condition of participation: Utilization review.)


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