Wis. Admin. Code DHS §124-11 - Utilization Review

This law requires that every hospital have a written utilization review plan to maximize patient care quality care while minimizing over or under-utilization of resources. The law requires that the plan include the following, at a minimum: 

• List of people responsible for performing the utilization review activities
• Conflict of interest policy
• Confidentiality policy applicable to review activities, and any findings and recommendations
• Description of the hospital’s process of identifying and resolving utilization-related problems
• Procedures for conducting review, including time period within which review must be performed
• Mechanism for provision of discharge planning

The law requires that the medical staff approve the written criteria used in the reviews.  The law allows non-physician health care professionals to participate in developing review criteria for their respective fields. The law requires that when it is determined that an admission or stay is medically not necessary, the attending physician be given a chance to present his or her opinion before a final determination is made. The law further states that records must be maintained for hospital utilization review activities and findings, and that regular reports need to made to the executive committee of the medical staff and the governing body.  Recommendations must be reported to administration.