Part One: Utilization Management Workshop Series: Best Practice Applications for the Hospital Setting (ODPT1W5039)-Utilization Management Workshop Series, Part One Recording

Video Transcription

Video Summary

This comprehensive webinar, led by Dr. Toni Sesta and Ms. Bev Cunningham from Case Management Concepts, LLC, provides an in-depth introduction to utilization management (UM) in healthcare case management, particularly focusing on its financial and operational aspects. The presenters emphasize the critical role of case managers—primarily nurses and social workers—in navigating the complex revenue cycle, payer contracts, and medical necessity criteria that dictate hospital compensation.<br /><br />Dr. Sesta and Ms. Cunningham detail the revenue cycle process, explaining how payer verification, medical necessity assessment, and physician documentation impact hospital reimbursement, especially under varying payment models such as Diagnosis-Related Groups (DRGs), per diem rates, stop-loss arrangements, and value-based payments. They highlight the challenges posed by diverse payer policies, notably Medicare Advantage's stricter adherence to the two-midnight rule and prior authorization demands.<br /><br />Utilization management is described as an active, critical thinking-driven process involving early assessment, medical necessity reviews conducted ideally on admission, and continuous collaboration with physicians and multidisciplinary teams. They stress the importance of bedside rounds to combine clinical observation with documentation review, improving accuracy in determining appropriate levels of care and avoiding unnecessary inpatient admissions or extended stays.<br /><br />The speakers also discuss the roles of various hospital departments in utilization management and underscore the necessity of case managers understanding payer contracts, denial processes, and appeal procedures to minimize revenue loss. They address common challenges such as delays in skilled nursing facility placements, lack of provider documentation, and emergency department holds without medical necessity.<br /><br />The session includes interactive polls illustrating best practices, such as engaging physicians early when medical necessity criteria are not met, documenting reviews separately from medical records, and prioritizing Medicare patients in observation for review. The webinar concludes with practical daily workflow recommendations for utilization reviews, emphasizing interdisciplinary collaboration, documentation integrity, and proactive discharge planning to optimize patient care and hospital revenue.

Keywords

utilization management

case management

healthcare finance

revenue cycle

payer contracts

medical necessity

hospital reimbursement

Diagnosis-Related Groups

per diem rates

stop-loss arrangements

value-based payments

Medicare Advantage

prior authorization

multidisciplinary collaboration

discharge planning