Part Two: Basics of Case Management, Five-Part Series-Basics of Case Management Series, Part 2 Recording

Video Transcription

Video Summary

Tony Sesta, a founding partner of Case Management Concepts, LLC, led a detailed discussion centered on case management and utilization management (UM), focusing on compliance, integration of best practices, and regulatory expectations under the Centers for Medicare and Medicaid Services (CMS). With over 25 years of experience in case management research, Dr. Sesta shared insights into historical shifts in case management models, notably from utilization review to case management, emphasizing their critical role in controlling quality and cost in healthcare settings.<br /><br />Dr. Sesta outlined how various roles in the healthcare system, including utilization, resource management, care coordination, and discharge and transitional planning, intertwine to enhance patient outcomes and ensure effective service delivery. She highlighted the importance of critical thinking and integration among these roles, breaking down traditional silos within healthcare teams to ensure more comprehensive, cohesive care plans.<br /><br />A significant portion of the discussion focused on compliance with CMS's utilization review standards, outlining necessary processes like utilization review plans and committees to ensure medical necessity and cost-effectiveness in healthcare provisions. Dr. Sesta also addressed the intricacies of billing, specifically through Condition Code 44 and Part B billing processes, providing clarity on navigating these areas in scenarios where patients do not meet medical necessity for inpatient stays.<br /><br />Importantly, Dr. Sesta advised on utilizing case management software to optimize documentation processes, streamline communication with payers, and manage denials effectively. Her presentation underscored the continuous effort required in utilization management to achieve organizational goals and improve patient satisfaction, indicating that a methodical, cross-disciplinary approach is vital in today's complex healthcare environment.

Keywords

Tony Sesta

Case Management Concepts

case management

utilization management

compliance

best practices

regulatory expectations

CMS

healthcare quality

cost control

care coordination

transitional planning

Condition Code 44

Part B billing

case management software