Utilization Management: Rules, Regulations and How-To’s

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.  In order 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.

The various types of Hospital-Issued Notices of Non-Coverage (HINNs) will be described with examples of how they are used. You will learn whether or not your utilization management committee is effective and compliant.

Webinar Objectives

• Learn what medical necessity is and how it applies to utilization management.
• Learn how to effectively complete a clinical review.
• Understand the compliance issues related to utilization management and how they apply to your daily practice.
• Discuss utilization at all hospital access points
• Review the various required documents to be shared with patients and families
• Describe the utilization committee and a utilization management plan

Webinar Highlights

• 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

Who Should Attend

• Director of Case Management
• 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