Utilization Management in a Value-Based Reimbursement System

Duration 60 Mins
Level Basic
Webinar ID IQW15C8906

  • 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

 

Overview of the webinar

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. 
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.

 

Who should attend?

  • Directors of Case Management
  • Directors of Social Work
  • Discharge Planners
  • Social Workers
  • RN Case Managers
  • Physician Advisors
  • Directors of Compliance
  • Directors of Quality and Outcomes

Why should you attend?

Utilization management was the first role applied in acute care case management models. It was first known of as utilization review but has evolved into something much more comprehensive than that. Today it encompasses elements of resource management and denials management as well and remains an integral part of the work of the acute care case manager. Are you up-to-date on the issues related to case management such as the Conditions of Participation from The Centers for Medicare and Medicaid Services? Do you know the best practices in performing this key role? Perhaps you have only recently taken on this complex and key role for your hospital. This program will review the role of utilization management as it applies to today’s contemporary case management models. Included will be best-practice suggestions for your practice with tips and strategies for stream-lining the process and making it as efficient as it can be. 

 

Faculty - Dr. Toni G. Cesta

Acclaimed Microsoft Excel expert David H. Ringstrom, CPA, is the president and owner of Accounting Advisors, Inc. based in Atlanta, Georgia. David founded Accounting Advisors in 1991 as a consulting-services business, but in 2009, he began teaching for continuing education providers as well. His mission since then has been to offer quality training on Excel and additional accounting software via live webcasts, on-demand self-study webcasts, and in-house engagements. More than 24 providers, located throughout the country as well as overseas, now look to David for their Excel and accounting software training needs.

David’s Excel courses cover the gamut of the software’s features and functions to provide CPAs as well as accounting and financial professionals the knowledge they need to work more efficiently and effectively in Excel. David is known for saying, “Either you work Excel, or it works you.” Based on this belief, he focuses on teaching users what they don’t know but should know about Excel. His comprehensive yet easy to understand presentations cover Excel 2016, 2013, 2010, and 2007. David’s webcasts are fast paced, and he welcomes attendees’ questions. In addition, his detailed handouts and slides serve as handy reference tools students can fall back on after participating in his webcasts or taking his self-study courses.

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