Part Three: Basics of Case Management, Five-Part Series-Basics of Case Mgt 2024 Part 2 Presentation

Basics of Case Mgt 2024 Part 2 Presentation

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