Admission Medical Necessity Reviews

Process

St. Clair Physician Adviser (PA) consultants perform concurrently, for hospital clients’ Case/Care Management Departments,  second-level admission medical necessity (AMN) case reviews with the objective of recommending the proper level of care [LOC- inpatient (IP), outpatient (OP)- observation, or OP ] for each patient. Such cases are referred by Case Managers who identify proposed admissions “not or questionably meeting” the InterQual or Milliman IP LOC criteria.

In performing the admission reviews in compliance with Medicare LOC regulations, St. Clair PA consultants assess concurrently each referred patient’s conditions, signs, symptoms, treatments, and/or test findings through real-time access to the involved medical record via EMR or faxed copies of record documents.  The PA consultant completes the review of such referred AMN cases with a “2-hour turnaround” response.

In the written AMN referral response, the PA consultant recommends what is the proper LOC with supporting clinical rationale. For any question regarding the recommended LOC, a PA consultant is available by telephone to discuss the case with the Hospital’s Case Manager/Medical Director/PA and, if desired, the responsible hospitalist or attending physician.

Benefit

St. Clair PAs provide assurance on their reviewed admissions that the patient-assigned LOC is consistent with the Medicare LOC regulations.

Pricing Approach

St. Clair has established a competitive professional fee per case which is based upon the volume of such monthly admission review referrals.