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Utilization Management: Rules, Regs, and How Tos

Toni G. Cesta
Recording Webinar Available @All Days
Recorded Webinar
  

Description

The rising cost of healthcare is one of the most significant issues in the world today. For far too many people, life-saving treatment is getting further out of reach. Conversely, hospitals also need help managing their costs and staying profitable. The answer to this dilemma is utilization management (UM). With UM, hospitals can manage their resources much more effectively while helping patients get their claims approved by their insurance providers.

Utilization management (UM) is a complex process that improves healthcare quality, reduces costs, and improves the population's overall health. Utilization management (UM) is a process that evaluates the efficiency, appropriateness, and medical necessity of the treatments, services, procedures, and facilities provided to patients on a case-by-case basis.

Utilization management also needs approval from several state and federal agencies, including Medicare. In addition, to integrate with various insurance companies and conform to their rules and regulations.

In this Webinar, you will discover ways to make your utilization management process more efficient. You'll also gain an understanding of the Conditions of Participation for Utilization Review and how they impact your role as a case manager. We'll explore the distinctions between utilization review and utilization management. You'll learn how to integrate medical necessity into the utilization management process, then explain the compliance aspects of utilization review, including the utilization management plan, the utilization management committee, Condition Code 44, and the two-midnight rule.

We'll show you how to include the two-midnight rule in your utilization management procedures and discuss the different types of clinical reviews that case managers perform.

You'll assess the effectiveness and compliance of your utilization management committee.

We'll describe the various types of Hospital-Issued Notices of Noncoverage (HINNs) and provide examples of how they are used.

Utilization Management Rules and Regulations:

  • Medicare Outpatient Observation Notice 
  • Quality Improvement Organization
  • Detailed Notice of Discharge 
  • Hospital Issued Notice of Noncoverage

Areas Covered:

  • Describe the differences between utilization review and utilization management.
  • Discuss the best strategies for managing utilization reviews and other issues related to utilization management.
  • Identify ways in which a vital utilization management process can reduce payment denials.
  • Compliance as it relates to utilization management.
  • Conditions of participation for utilization review.
  • Components of a compliant utilization review plan and committee.
  • Focusing on Condition Code 44.
  • 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 Noncoverage – HINNs.

Why Should You Attend:

The Webinar will streamline your utilization management process and help you understand the Conditions of Participation for Utilization Review and how they impact your work as a case manager. The Webinar will discuss the differences between utilization review and utilization management. Incorporating medical necessity into the utilization management process will be explained. This will be followed by examining the compliance components for utilization review, including the utilization management plan, the utilization management committee, Condition Code 44, and the two-midnight rule.

Who Should Attend:

  • Director of Social Work
  • Case Managers
  • Social Workers
  • Vice President of Case Management
  • Physician Advisor
  • Emergency Department physicians
  • Directors of Nursing
  • Directors of Compliance
  • Directors of Finance
  • Directors of Nursing

Training Options

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Recording
   $199  

Digital Download
   $229  

Transcript (PDF)
   $199  

Tokyo

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