Description

In this jam-packed program, you will learn how to streamline 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. 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, and 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 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.

Learning Objectives:-

• Understand the definition of medical necessity.
• Review the utilization management components of the Conditions of Participation.
• Discuss the Condition Code 44 process and your role.
• Describe the different types of HINNs (Hospital Issues Notices of Non-Coverage and when to use them.
• Learn how the compliance components of utilization review.
• Relate the components of utilization management to denial management.
• Review the different types of clinical reviews.

Areas Covered in the Session:-

• The differences between utilization review and utilization management
• The definition of medical necessity
• How to balance the 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
• Live Q&A Session

Who Should Attend:-

• RN Case Managers
• Case Managers
• Social Workers
• Vice Presidents of Operations
• Director of Case Management
• Case Managers
• Directors and Vice Presidents of Nursing
• Directors of Patient Flow
• Director of Revenue Cycle
• Chief Financial Officers
• Chief Operations Officers
• Chief Medical Officer
• Hospitalists
• Director of Quality Management
• Nursing Home Directors
• Director of Home Care
• Director of Finance
• Vice President of Case Management
• Hospitalists
• Physician Advisors
• Directors of Social Work