Part Four: Utilization Management Workshop Series: Best Practice Applications for the Hospital Setting (ODPT4W5039)-2025 Utilization Management Series Part 4 Presentation

2025 Utilization Management Series Part 4 Presentation

Pdf Summary

The "Utilization Management Workshop: Application of the UR Process" webinar by the Georgia Hospital Association focuses on optimizing Emergency Department (ED) case management and utilization management (UM) to ensure medically necessary, appropriate, and cost-effective patient care. ED case managers play a key role in facilitating patient flow, coordinating interdisciplinary care, assessing medical necessity, planning admissions or discharges, and collaborating closely with physicians and payers.<br /><br />Key functions of ED case managers include timely care, arranging community resources, expediting tests, and communicating across care teams. They review admission appropriateness, identify readmission risks, and support appeals for denials, working alongside UM case managers and physician advisors. Clerical support staff assist with administrative aspects like insurance authorization, documentation, and patient notifications to allow clinical staff to work at their highest licensure.<br /><br />Strong physician collaboration is critical as documentation quality often impacts reimbursement and denial prevention. Strategies to engage physicians involve real-time feedback, education through case studies, and participation in denial management processes. Physician advisors serve as essential liaisons between clinical staff, hospital administration, and payers to support complex cases and appeals.<br /><br />The webinar addresses challenges with payer contracts, emphasizing the need for UM language in contracts covering medical necessity criteria, peer-to-peer review processes, and appeal rights. It highlights the importance of understanding evolving regulations like the 2-Midnight Rule, which governs inpatient versus observation status based on expected length of stay and admission documentation ("day zero" criteria).<br /><br />Case studies focus on real-world scenarios involving Medicare Advantage denials, peer-to-peer reviews, and appropriate responses including Condition Code 44 usage, emphasizing accurate documentation and timely communication. The workshop underscores the hospital’s role in fortifying the admission narrative, educating staff on UM processes, and fostering collaborative appeal efforts to minimize denials and protect hospital reimbursement.<br /><br />Overall, the session equips case managers, physicians, and UM staff with practical tools and strategies for effective utilization review, medical necessity determinations, and payer negotiations, enhancing care delivery and financial outcomes.

Keywords

Utilization Management

Emergency Department

Case Management

Medical Necessity

Physician Collaboration

Payer Contracts

2-Midnight Rule

Denial Management

Peer-to-Peer Review

Medicare Advantage Denials