Key Points:

  • Utilization management definition
  • Difference between utilization review and utilization management
  • Medical necessity defined
  • UM processes for, and components of, medical necessity
  • When a patient meets medical necessity
  • When a patient does not meet medical necessity
  • Compliance components of medical necessity
  • Conditions of Participation by CMS and utilization management
  • Essential case management department activities
  • Utilization management and billing
  • Utilization management and reimbursement
  • Best practice in clinical reviews
  • Managing utilization from the bedside
  • Appropriate UM documentation
  • Physician collaboration in utilization management
  • Practicing physicians
  • Physician advisor
  • Utilization Management Committee physicians
  • Incorporating UM into your daily routine
  • Managing denials before they happen
  • UM documentation sources
  • The separate function of Utilization management separated from the case management function.

Fundamental Utilization Management Practices for Value Based World


In this jam-packed program, you will learn how to streamline your utilization management process as well as understand the conditions of participation(CoP) for utilization review and how they impact your work as a case manager. The webinar will also discuss the differences between utilization review and utilization management.

The process for incorporating medical necessity into the process of utilization management will be explained followed by a discussion on the compliance components for utilization review including the utilization management plan, the utilization management committee, Condition Code 44 and the two-midnight rule. Also, the various types of clinical reviews performed by the case manager and how to incorporate the two-midnight rule into your utilization management process will be explained. You will learn whether or not your utilization management committee is effective and compliant.

The various types and uses of Hospital-Issued Notices of Non-Coverage (HINNs) will be described with examples. You will learn strategies for passing a survey on the Conditions of Examples of utilization review committee reports will round out this comprehensive program.

Why Should You Attend?

Utilization management is one of the fundamental roles of the hospital case manager, and as such, each RN case manager should be aware of the rules of utilization as put out by the Centers for Medicare and Medicaid Services (CMS) as well as how utilization management relates to value-based reimbursement.  Stay current on this topic and have a chance to review forms and other processes you need to be at the top of your game.

Session Highlights:
  • Understand the Conditions of Participation for Utilization Review
  • Discuss the compliance elements related to utilization review including HINNs, Condition Code 44, etc.
  • Describe the ways in which value-based purchasing has impacted utilization management.
  • Review how utilization management can be incorporated into the daily work of the case manager.
Who Should Attend?
  • RN Case Managers
  • Social Workers
  • Directors of Case Management
  • Directors of Social Work
  • Physician Advisors
  • Directors of Finance
Avail 50% Off!! Use Coupon Code "SYMCARE"
Recorded $ 213.00
Transcript $ 213.00
DVD $ 223.00
Recorded + Transcript $ 323.00
DVD + Recorded $ 333.00
DVD + Transcript $ 333.00
Total $ 0.00

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