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Hospital Case Management and the Utilization Review Committee

Orland, Richard A. MD

doi: 10.1097/NCM.0b013e318212f5a1
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Purpose/Objectives: This article describes the overall regulatory mandate governing the Utilization Review Committee (URC) in the hospital setting. General structure, function, and meeting format of the URC are important considerations. Furthermore, the URC can serve as a vital platform for medical staff leadership and case management practice to use pertinent risk-adjusted data to drive needed change at the organizational, departmental, service line, and physician level. A case history illustrates the importance of these issues.

Primary Practice Setting: Acute care hospitals.

Implications for case management practiceCase management staff, medical advisors, and physician leaders play important roles in driving changes. The URC will become ever-more important in the rapidly accelerating changes, driving heightened accountability on the part of hospitals.

Richard A. Orland, MD, is the Medical Advisor of the Care Management Program for Saint Thomas Health Services. Board certified in both Internal Medicine and Insurance Medicine, Dr. Orland is a seasoned clinician and physician executive. He has 15 years of clinical experience and 25 years of medical management experience encompassing both providers and payers.

Address correspondence to Richard A. Orland, MD, Care Management Program, Saint Thomas Health Services, 2000 Church Street, 5th Floor West Building, Nashville, TN 37236 (richard.orland@baptisthospital.com).

© 2011 Lippincott Williams & Wilkins, Inc.