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 works to improve healthcare quality, reduce costs, and improve 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 Non-Coverage (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

Presenter Information:

Name: 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”.