Fundamentals of Utilization Management: A Review of the Conditions of Participation for Utilization Review


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Attend this webinar to learn how to stream-line your utilization management process and understand the Conditions of Participation for Utilization Review and how they impact your work as a case manager.

Why Should You Attend:

In this jam-packed program, we will discuss the differences between utilization review and utilization management. The process of 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, the various types of clinical reviews performed by the case manager will be explained.

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.

Areas Covered in the Webinar:

  • 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

Who Will Benefit:

  • RN Case Managers
  • Social Workers
  • Directors of Case Management
  • Directors of Social Work
  • Physician Advisors
  • Directors of Compliance
  • Director of Nursing
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