A good place for compliance officers to consider being aware of ongoing monitoring of potential compliance risk areas is to understand and partner with utilization review. It is good to understand the role of utilization review and whether the hospital has an agreement with a quality improvement organization (QIO) to assume binding review for the hospital to meet compliance with the Medicare conditions of participation for utilization review (UR).

According to the State Operations Manual, Appendix A, “if the hospital does not satisfy one of the exception criteria at §482.30(a), it must have a UR plan in effect which provides for review of services provided to Medicare and Medicaid beneficiaries.”^[1]