Fundamentals of Utilization Management: A Review of the Conditions of Participation for Utilization Review

The Centers for Medicare and Medicaid Services (CMS) provides us with two Conditions of Participation that apply to the work of case management professionals. These include the Conditions of Participation for Discharge Planning and the Conditions of Participation for Utilization Review. This webinar will focus on these rules as they apply to the role of utilization review. For case management departments to be compliant with these regulations, RN and social work case managers must understand these ‘rules of the road’ for utilization review and work within their boundaries.

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 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.

Webinar Objectives

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.

Webinar Agenda

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

Webinar Highlights

Review the conditions of Participation for Utilization Review
Discuss how clinical reviews relate to medical necessity
Understand the areas of compliance for utilization review and how to maintain compliance
Describe the three types of clinical reviews and how each is used.
Review the types of HINNs and how to properly use them
Discuss the 2 Midnight Rule, access point case management and utilization management.

Who Should Attend

RN Case Managers
Social Workers
Directors of Case Management
Directors of Social Work
Physician Advisors
Directors of Compliance
Director of Nursing

Toni Cesta

Toni Cesta, Ph.D., RN, FAAN is partner and health care consultant at Case Management Concepts, LLC, a consulting company which assists institutions in designing, implementing and evaluating acute care and community case management models and 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. Dr. Cesta is considered on of the primary thought leaders in the field of case management. She has written nine books on the topic of case management and 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. Dr Cesta has presented topics on case management at national and international conferences and workshops. Dr Cesta has held positions as case manager, director of case management, Vice President of Patient Flow Optimization and Senior Vice President of Operational Efficient and Capacity Management. She also completed 7 years as Commissioner for Case Management Certification.