Part Four: Utilization Management Workshop Series: Best Practice Applications for the Hospital Setting (ODPT4W5039)-Utilization Management Workshop Series, Part Four Recording

Video Transcription

Video Summary

This webinar session, led by Bev Cunningham and Dr. Tony Sesta from Case Management Concepts, LLC, focuses on advanced case management topics critical for effective hospital operations. With over 25 years in case management, both speakers emphasize the necessity of integration and collaboration across hospital departments, particularly the Emergency Department (ED) and utilization management (UM). They explain that case management in the ED is essential, acting as a gatekeeper to ensure patients receive the right level of care and facilitating patient flow efficiently.<br /><br />The session stresses the importance of strong teamwork among ED case managers, utilization managers, social workers, and clerical support to handle the documentation-heavy workload. Bev highlights the critical role of physician collaboration, noting that many physicians lack training in utilization management rules. Effective communication and education, particularly through peer-to-peer discussions led by skilled physician advisors, are essential in improving medical necessity documentation and reducing denials.<br /><br />Different types of physician advisors—internal, external, and hybrid—are discussed, including their roles in utilization management, discharge planning, and denial appeals. The presenters also stress the importance of understanding payer contracts and medical necessity criteria, which are often complex and not well known by hospital staff.<br /><br />Case studies illustrate challenges in level-of-care decisions, such as correct use of observation versus inpatient orders, and the evolving "Two Midnight Rule" and new regulations like the impending "Day Zero" law, which restrict retrospective inpatient denials based on post-admission outcomes.<br /><br />The session concludes with interactive polls and discussions to reinforce learning, emphasizing the need to educate hospital staff and physicians on documentation, compliance, and collaboration with payers to optimize reimbursement and patient care outcomes.

Keywords

case management

hospital operations

Emergency Department

utilization management

patient flow

physician collaboration

medical necessity

denial appeals

discharge planning

payer contracts

Two Midnight Rule

Day Zero law

documentation compliance