The financial benefits of an effective hospitalwide quality assurance/utilization management program.
This article describes the organizational structure and functions of the quality assurance/utilization management (QA/UM) department at The Johns Hopkins Hospital (Baltimore), which has developed a proactive QA/UM program for identifying opportunities to control inappropriate inpatient admissions, shorten a patient's length of stay, monitor the use of ancillary services, and improve physician documentation in patient medical records. In addition, the QA/UM department has developed and implemented an aggressive third-party appeal mechanism to ensure that the institution has an effective UM program. The QA/UM department annually recovers more than 3 million dollars for the hospital by aggressively appealing third-party payer denials. Specific chart-review variables are outlined.
Shockney
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Utilization & Risk Management, Johns Hopkins Hospital, Baltimore, MD 21205.
D015142:Baltimore; D006746:Hospital Bed Capacity, 500 and over; D006751:Hospital Information Systems; D006785:Hospitals, University / Q000458:organization & administration / Q000592:standards*; D007349:Insurance, Health, Reimbursement; D011366:Professional Review Organizations; D011785:Quality Assurance, Health Care / Q000191:economics / Q000458:organization & administration*; D011786:Quality Control; D012984:Software; D014600:Utilization Review / Q000191:economics / Q000458:organization & administration*