Chapter 16: Utilization Review for Post-Acute Rehabilitation Services-Residential

16.1 Overview

Utilization reviews help ensure that the appropriate scope and level of services are provided to CRS consumers The utilization review may be performed as a prospective, concurrent, or retrospective review.

16.2 Types of Utilization Reviews

Prospective Reviews - Services are reviewed before authorization of the Individual Program Plan to determine the appropriate level and scope. These reviews may be conducted face-to-face.

Concurrent Reviews – Services are reviewed when the consumer is receiving services.

Retrospective Reviews – Services are reviewed after delivery or discontinuation of services, or after decisions have been made for authorization. These reviews ensure that services billed according to the tiered rate were delivered specified by the rate and if services were provided as recommended by the Individualized Program Plan and interdisciplinary team.

16.3 Utilization Review Processes

Reviews of a consumer’s records, services, and billing can occur from the point of entry into the CRS program until after the consumer ends or completes treatment and may include prospective, concurrent and retrospective review activities.

The purpose of a CRS utilization review is to:

  • ensure the program fiscal integrity of the provider;
  • address the state laws and regulations that program funds be spent only as allowed; and
  • ensure that services are provided based on medical necessity and are continued based on their efficacy.

A consumer’s records may be chosen for review through a random sample or based on billing issues noted by CRS program staff members.

16.3.1 Prospective Reviews

During a prospective review, services are reviewed before they are authorized to determine if the consumer and/or current processes were followed.

The purpose is to ensure that:

  • a consumer meets eligibility requirements;
  • services will meet the consumer’s needs; and
  • CRS program staff members are following CRS policies and procedures.

CRS program managers perform prospective reviews. The types of documentation and activities reviewed include:

  • intake and assessment information;
  • a diagnostic interviews;
  • consumer’s records to support eligible diagnosis or diagnoses;
  • a determination of eligibility by a CRS counselor;
  • basic eligibility requirements, as they apply to the consumer’s unique case and circumstances;
  • the consumer’s Individualized Written Rehabilitation Plan;
  • assessments made at the request of or by the CRS counselor; and
  • interviews held with the consumer, consumer’s family and/or guardian.

Managers complete a prospective review using case review documents. If a case is chosen for prospective review, the counselor is notified and is given a copy of the review.

16.3.2 Concurrent and/or Retrospective Reviews

Utilization reviews can be conducted while the consumer is receiving services or reviews can be conducted retrospectively.

The reviews are conducted to ensure that:

  • a consumer received services;
  • the services were provided as often and for as long as specified in the consumer’s Individualized Written Rehabilitation Plan (IWRP) and treatment plan;
  • the treatment met the consumer’s needs;
  • billing occurred as specified in policy and standards; and
  • CRS policies and procedures were followed by CRS program staff members.

The reviews may include:

  • the Individualized Program Plan and IWRP;
  • medical and/or nursing assessment and diagnoses;
  • therapy assessments and therapy notes, along with treatment plans, and treatment data;
  • changes in treatment strategies based on data and assessments;
  • interdisciplinary team meeting summaries;
  • tier billing logs;
  • consumer schedules;
  • consent forms;
  • consumer’s restraints reports;
  • care provided by the facility, paraprofessionals, and professionals;
  • discharge planning notes;
  • documentation confirming all billing activities;
  • interviews held with the consumer and the consumer’s family or guardian;
  • notes from on-site visits;
  • outings taken by the consumer; and
  • documentation to support billing or care, as required for review by CRS policy and standards.

CRS program staff members will conduct concurrent and/or retrospective utilization reviews and then document the results of each review in ReHabWorks.

16.4 Review Outcomes

Recoupment of Overpayments

Recoupment is required if the results of a utilization review indicate overpayment for services delivered, payment made for services not delivered, or payment made for services provided without preauthorization. The appropriate agency or agency designee notifies the provider in writing about the overpayment identified and explains the method of recoupment to be used.

Administrative Actions and Sanctions

The administrative actions or sanctions form a utilization review may result in one or more of the following being taken by the agency or agency's designee:

  1. Closure of the review with written notification to the provider.
  2. Discussion and interpretation of results of the review with the provider.
  3. Referral to the appropriate state licensing board or the Texas Office of the Inspector General.
  4. Any other remedies authorized by rule, regulation, statute, or contract.

16.5 Appeal Process for Providers

The provider may appeal the findings of a utilization review; specifically, billing for services. For detailed information pertaining to the appeals process for providers, refer to the CRS Standards for Providers, Chapter 8: Utilization Review for Post-Acute Rehabilitation Residential Services for Traumatic Brain Injury, 8.5 Appeals Process for Providers.