Description
Overview of the webinar
In this jam-packed program you will learn how to stream-line your utilization management process as well as understand the Conditions of Participation for Utilization Review and how they impact on your work as a case manager. We will discuss the differences between utilization review and utilization management. The process for incorporating medical necessity into the process of utilization management will be explained. This will be followed by a discussion of the compliance components for utilization review including the utilization management plan, the utilization management committee, Condition Code 44 and the two-midnight rule.
How to incorporate the two midnight rule into your utilization management process. Also explained will be the various types of clinical reviews performed by the case manager. You will learn whether or not your utilization management committee is effective and compliant. The various types of Hospital-Issued Notices of Non-Coverage (HINNs) will be described with examples of how they are used. You will learn strategies for passing a survey on the Conditions of Examples of utilization review committee reports will round out this comprehensive program.
Session Highlights:
- The differences between utilization review and utilization management
- The definition of medical necessity
- How to balance financial and clinical medical necessity
- Compliance as it relates to utilization management
- Conditions of participation for utilization review
- Components of a compliant utilization review plan
- Components of a compliant utilization review committee
- Condition Code 44
- Provider Liable
- Guidelines for utilization review surveys
- Guidelines for admission and continued stays
- Clinical aspects affecting medical necessity
- Three types of utilization management
- Utilization management and access point case management
- Sample utilization management reports
- The two-midnight rule and utilization management
- Hospital Issued Notices of Non-Coverage – HINNs
- Denial management as a component of utilization management
Who should attend ?
- Directors of Case Management
- Directors of Social Work
- Discharge Planners
- Social Workers
- RN Case Managers
- Physician Advisors
- Directors of Compliance
- Directors of Quality and Outcomes
Toni G. Cesta, Ph.D., RN, FAAN is Partner and Health Care Consultant in Case Management Concepts, LLC, a consulting company which assists institutions in designing, implementing and evaluating acute care and community case management models, providing on-site education to case management staff, and strategies for assisting health care organizations in improving their case management department’s efficiency and effectiveness.
