Part Two: Case Management Boot Camp 2026: Fundamentals for Everyday Practice (ODPT2W6013)-Case Management Boot Camp 2026, Part Two Presentation

Case Management Boot Camp 2026, Part Two Presentation

Pdf Summary

Module 2 of the Georgia Hospital Association’s Case Management Boot Camp 2026 explains how case managers apply CMS utilization management (UM) rules in daily practice. It frames case management around four core roles—utilization management, resource management, care coordination, and discharge/transitional planning—emphasizing that early case management aimed to control bedside quality and costs.<br /><br />The module distinguishes utilization review (UR) from UM: UR is a passive audit of documentation, while UM is an active, operational process that collaborates with clinicians to ensure medically necessary care is delivered and clearly documented. Medical necessity is defined as evidence-based care that is neither more nor less than what the patient needs at a specific time. Best practice UM occurs at the bedside, not only via chart review, because bedside assessment reveals functional, cognitive, psychosocial, safety, and discharge-readiness issues often missing from documentation.<br /><br />CMS Conditions of Participation require hospitals to maintain a UR plan and UR committee. Case managers perform first-level reviews but cannot independently declare lack of medical necessity; unresolved cases must be referred to a physician advisor/second-level review (which may include UR committee physicians). The module outlines workflows for cases that meet criteria and those that do not, including escalation and potential additional committee review.<br /><br />Key compliance topics include correct status and orders (inpatient vs observation vs outpatient-in-a-bed), Medicare’s Two-Midnight Rule (including timing “clock” rules and exceptions), and accurate billing pathways. Condition Code 44 allows changing an inpatient to outpatient/observation before discharge with UR committee involvement, attending concurrence, and patient notification (MOON). If discovered after discharge, “Part B billing/self-denial” (e.g., Code 121/provider liable) may apply with less reimbursement.<br /><br />The training also covers observation services, new prospective appeal rights for certain inpatient-to-observation reclassifications (MCSN, QIO processes), discharge notices (IMM updates), optional ABN/HINN use, inpatient-only procedures, audit risks (OIG short-stay focus), and denial prevention/management strategies. It concludes with a practical “day in the life” UM checklist and stresses urgency and multidisciplinary coordination to reduce avoidable denials.

Keywords

case management

utilization management

medical necessity

utilization review

CMS Conditions of Participation

Two-Midnight Rule

Condition Code 44

observation services

physician advisor

denial prevention