Utilization Management in a Value-Based Reimbursement System

Product Id IQW15C8906
Speaker Toni G. Cesta
Level Basic
Duration 60 Mins
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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.

 

Utilization management was the first role applied in acute care case management models. It was first known of as utilization review but has evolved into something much more comprehensive than that. Today it encompasses elements of resource management and denials management as well and remains an integral part of the work of the acute care case manager. Are you up-to-date on the issues related to case management such as the Conditions of Participation from The Centers for Medicare and Medicaid Services? Do you know the best practices in performing this key role? Perhaps you have only recently taken on this complex and key role for your hospital. This program will review the role of utilization management as it applies to today’s contemporary case management models. Included will be best-practice suggestions for your practice with tips and strategies for stream-lining the process and making it as efficient as it can be. 

 

  • 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

 

  • 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, with an eye on structure, process and outcome measures for nurse case managers and social workers. 
The author of nine books, and a frequently sought after speaker, lecturer and consultant, Dr. Cesta is considered one of the primary thought leaders in the field of case management. Among her books are included the “The Case Managers Survival Guide” and “Core Skills for Hospital Case Managers”.
Dr. Cesta writes a monthly column called “Case Management Insider” in the Hospital Case Management newsletter in which she shares insights and information on current issues and trends in case management.  She is a past commissioner for the Commission for Case Management Certification. She has held positions as Senior Vice President, Corporate Vice President, Director of Case Management and professor of case management.