QUESTION: Does our Utilization Review Committee have to be a Medical Staff committee, or can it be a Hospital committee?
ANSWER: In our experience, some hospitals do have a utilization review committee set up as a Medical Staff committee, but many do not. There is no explicit regulatory requirement or accreditation standard obligating a hospital to have a Medical Staff utilization review committee. For example, the Centers for Medicare & Medicaid Services (“CMS”) Conditions of Participation for Hospitals require hospitals to have a utilization review plan and a utilization review committee. The committee, per the Conditions of Participation, has to be a “staff committee of the institution” with at least two physicians as members. The requirement can be satisfied by “a group outside the institution” such as one established by local medical societies. CMS includes the utilization review requirements in the Conditions of Participation in a separate section from the medical staff requirements. The Medical Staff sections of the Conditions of Participation do not even mention utilization review. Even though the Conditions of Participation note that a utilization review committee has to be a “staff committee,” this is different from a “medical staff committee.” CMS knows how to signify when something falls under the purview of the medical staff and the fact that CMS left out “medical staff” when describing the requirements for the utilization review committee is significant. Furthermore, the Conditions of Participation state that the committee has to be a committee of the “institution,” which signifies “hospital” as opposed to Medical Staff. The fact that the utilization review committee requirement can be satisfied by a “group outside the institution” (that would not be a medical staff committee) also demonstrates that it does not need a medical staff committee. Keep in mind that if you decide to have the utilization review committee as a hospital committee, we recommend that you confirm that your state does not require that the committee be a medical staff committee.
That being said, we are aware of at least one client who received feedback from the CMS Survey & Certification Group, Division of Acute Care Services that the utilization review committee “must be a committee or subcommittee of the medical staff.” Nonetheless, this feedback, as noted above, is not consistent with the Conditions of Participation and we are not aware of CMS citing any hospital for having a Hospital utilization review committee. It is also not consistent with current practice of many hospitals whose utilization review committees are multi-disciplinary hospital committees with membership comprised of both practitioners and administrative personnel such as directors of coordinated care, billing staff, and internal audit staff.