Ohio Utilization Review
of Inpatient Psychiatric Care
Health
Care Excel (HCE) is a contractor to the Ohio Department
of Mental Health (ODMH), providing a comprehensive
monitoring program staffed by professionals who have
detailed knowledge and understanding of the federal and
state guidelines.HCE is responsible for the contractual oversight of the Utilization Review of Inpatient Psychiatric Care for the ODMH, performing on-site post-payment reviews (OSPPR) for medical necessity. The three components of the program include Preadmission Certification, Post-Payment Reviews, and Provider Education.
HCE's objective is to monitor the following.
- Clinical appropriateness of inpatient psychiatric care
- Unnecessary or inappropriate use of Medicaid services and excess payment
- Quality of inpatient care
- Adequacy with which facilities providing psychiatric care meet applicable provisions of state and federal guidelines governing the care
The utilization review processes are structured to monitor the following elements.
- Medical necessity for inpatient care
- Premature discharge
- Appropriateness of readmission
- Children's admissions
- Validation of the Diagnosis Related Group (DRG) assignment
- Appropriateness of treatment and discharge planning
- Compliance with the pre-certification process
- Lengths of stay
Monitoring is carried out through the following actions.
- Development of medical necessity criteria
- Preadmission certification
- Selection of cases for post-payment review
- Provider appeals
- Recipient hearings
- Provider training
- Management reporting systems
- Intensive case or facility review
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