Utilization Management in a Value-Based Reimbursement System

Duration 60 Mins
Level Basic & Intermediate
Webinar ID IQW19A0144

  • 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

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.

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

Why should you attend?

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.

Faculty - Dr. Toni G. Cesta

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.

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.

Dr. Cesta writes a monthly column called “Case Management Insider” in the Hospital Case Management journal in which she shares insights and information on current issues and trends in case management.

Prior to her current work as a case management consultant, Dr. Cesta was Senior Vice President – Operational Efficiency and Capacity Management at Lutheran Medical Center in Brooklyn, New York. She was responsible for case management, social work, discharge planning, utilization management, denial management, bed management, the patient navigator program, the clinical documentation improvement program and systems process improvement.  Prior to her position as Senior Vice President at Lutheran Medical Center, Dr. Cesta has held positions as Corporate Vice President for Patient Flow Optimization at the North Shore – Long Island Jewish Health System and Director of Case Management, Saint Vincents Catholic Medical Centers of New York, in New York City and also designed and implemented a Master’s of Nursing in Case Management  Program and Post-Master’s Certificate Program in Case Management at Pace University in Pleasantville, New York.  Dr. Cesta completed seven years as a Commissioner for the Commission for Case Manager Certification.

Dr. Cesta has presented topics on case management at national and international conferences and workshops.  Her books include “Nursing Case Management: From Essentials to Advanced Practice Applications”, “The Case Manager’s Survival Guide: Winning Strategies in the New Healthcare Environment”, “The Case Manager’s Survival Guide: Winning Strategies for Clinical Practice”, “Survival Strategies for Nurses in Managed Care” and “Core Skills for Hospital Case Managers”.

 

 

 

For group or any booking support, contact: