Fundamental Utilization Management Practices For Value Based World

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Key Points:

Utilization management definition
Difference between utilization review and utilization management
Medical necessity defined
UM processes for, and components of, medical necessity
When patient meets medical necessity
When patient does not meet medical necessity
Compliance components of medical necessity
Conditions of Participation by CMS and utilization management
Essential case management department activities
Utilization management and billing
Utilization management and reimbursement
Best practice in clinical reviews
Managing utilization from the bedside
Appropriate UM documentation
Physician collaboration in utilization management
Practicing physicians
Physician advisor
Utilization Management Committee physicians
Incorporating UM into your daily routine
Managing denials before they happen
UM documentation sources
Utilization management separated from the case management function

Description:

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 your work as a case manager. Differences between utilization review and utilization management will be discussed.

The process for incorporating medical necessity into the process of utilization management will be explained 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. Also the various types of clinical reviews performed by the case manager and how to incorporate the two midnight rule into your utilization management process will be explained. 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.

Why Should You Attend?

Utilization management is one of the fundamental roles of the hospital case manager and as such each RN case manager should be aware of the rules of utilization as put out by the Centers for Medicare and Medicaid Services (CMS) as well as how utilization management relates to value-based reimbursement.  Stay current on this topic and have a chance to review forms and other processes you need to be at the top of your game.

Session Highlights:

Understand the Conditions of Participation for Utilization Review
Discuss the compliance elements related to utilization review including HINNs, Condition Code 44, etc.
Describe the ways in which value-based purchasing has impacted utilization management.
Review how utilization management can be incorporated into the daily work of the case manager.

Who Should Attend?

RN Case Managers
Social Workers
Directors of Case Management
Directors of Social Work
Physician Advisors
Directors of Finance