Part Two: 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 Georgia Hospital Association's Case Management Boot Camp 2024, led by Toni Cesta of Case Management Concepts, focuses on Utilization Management (UM) in healthcare. The training covers essential components such as medical necessity, rules, regulations, and strategies to integrate UM effectively into case management practices.<br /><br />UM involves actively assessing and documenting the medical necessity and appropriateness of healthcare services. It aligns with roles like discharge planning, care coordination, and resource management, requiring critical thinking and flexibility in handling various payer reimbursement structures. The process demands that the attending physician be involved when documentation does not support efficient, cost-effective care. In cases where the physician cannot add necessary documentation, a referral to a physician advisor is mandatory.<br /><br />The training outlines how to apply UM principles to ensure appropriate, efficient, and cost-effective patient care. For instance, when patients do not meet medical necessity criteria, discussions with physicians and possible second-level reviews by physician advisors are advised. Additionally, compliance with CMS regulations, such as the Conditions of Participation for hospitals, requires hospitals to have a Utilization Review (UR) plan and committee to review service necessity and duration of stays.<br /><br />Billing processes like Condition Code 44 address situations where a patient’s inpatient order does not meet medical necessity, allowing billing under Medicare Part B. This underscores the importance of accurate documentation and appropriate billing, ensuring that medical necessity criteria and UM processes are thoroughly followed.<br /><br />Overall, effective UM practices in case management involve timely assessments, integrating UM with other roles, collaborating with physicians, and complying with regulatory requirements across all hospital entry points. This approach reduces denials and enhances patient care outcomes while ensuring compliance with reimbursement processes.

Keywords

Georgia Hospital Association

Case Management Boot Camp 2024

Utilization Management

medical necessity

discharge planning

care coordination

CMS regulations

Condition Code 44

physician advisor

reimbursement processes