false
Catalog
Part Three: Basics of Case Management, Five-Part S ...
Basics of Case Mgt 2024 Part 2 Presentation
Basics of Case Mgt 2024 Part 2 Presentation
Back to course
Pdf Summary
The "Case Management Boot Camp 2024" organized by the Georgia Hospital Association delves into the intricacies and essential practices surrounding Utilization Management (UM) in healthcare. As outlined by Toni Cesta, PhD, RN, FAAN, the program provides a comprehensive look at the fundamental roles of case managers: Utilization Management, Resource Management, Care Coordination, and Discharge and Transitional Planning. The boot camp emphasizes the proactive nature of Utilization Management compared to the passive Utilization Review, focusing on ensuring medical necessity through collaboration with the healthcare team and proper documentation.<br /><br />UM is presented as a critical process designed to verify the appropriateness and medical necessity of healthcare services. Key components include engaging attending physicians in reviewing and enhancing documentation that justifies medical necessity, and explaining protocols in which non-physician staff like UR nurses cannot independently determine the lack of medical necessity.<br /><br />The document also covers regulatory frameworks, such as CMS Conditions of Participation which hospitals must adhere to for Medicare and Medicaid, mandating hospitals to maintain a UR plan and committee. Utilization Management processes are outlined for when patients meet or do not meet medical necessity criteria, highlighting the significance of maintaining compliance with CMS rules, and addressing potential billing complications via tools such as Condition Code 44 for Medicare billing when inpatient criteria aren’t met.<br /><br />The module summarizes effective strategies for case managers, emphasizing a seamless integration of UM principles into daily practices and promoting active communication between staff and physicians. The importance of accurate documentation and timely medical necessity reviews is underscored to prevent denials or manage them effectively, focusing on a proactive approach to utilization management that minimizes revenue loss and enhances patient care efficiency.
Keywords
Case Management Boot Camp
Utilization Management
Georgia Hospital Association
Toni Cesta
Care Coordination
Discharge Planning
CMS Conditions of Participation
Medical Necessity
Resource Management
Condition Code 44
380 Interstate North Parkway SE
Suite 150
Atlanta, GA 30339
Phone: 770-249-4500
About Us
Community Healths
Contact Us
Programs
© Copyright 2024 Georgia Hospital Association
×
Please select your language
1
English