Developing a Utilization Management/ Quality Improvement Program in Home Health

Abstract

In 1982 a Prospective Payment System (PPS) was brought to hospital reimbursement with the enactment of the Tax Equity and Fiscal Responsibility Act (TEFRA). Diagnosis-related groups (DRGs) became the form of PPS used to reimburse hospitals. In that same year new documentation requirements came to home health. The plan of treatment (485) and the medical update form (486) gave Medicare the ability to more closely monitor and regulate the home health care industry. The completion of these forms, which required concurrent and retrospective review of the medical record, became increasingly problematic for home health care agencies to manage. Allegheny Home Care/Hospice first established a utilization review (UR) department in 1986 and six field staff nurses were recruited to fill positions as UR nurses.