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

Video Transcription

Video Summary

The session launches Module 2 on Utilization Management (UM), distinguishing passive “utilization review” (chart audits) from active UM, which proactively determines <strong>medical necessity</strong> and the <strong>appropriate level/setting of care</strong> using evidence-based criteria (e.g., InterQual/Milliman) plus strong documentation. The presenter argues UM is more accurate when integrated into interdisciplinary rounds and <strong>bedside assessment</strong>, since insurers only see charts.

Key regulatory drivers include Medicare <strong>Conditions of Participation</strong> requiring a UR plan and a UR committee (with at least two practitioners) focusing on outlier long stays and high-cost cases. Nurses perform first-level reviews but <strong>cannot deny medical necessity</strong>; cases that don’t meet criteria must be escalated to a <strong>physician advisor</strong> or UR committee for second-level review and potential discharge/status change.

The webinar reviews correct <strong>orders and statuses</strong> (inpatient vs observation/outpatient), Medicare’s <strong>two-midnight rule</strong> (including documentation requirements and exceptions), and how observation affects SNF eligibility (observation nights do not count toward the 3-midnight SNF rule). It explains billing/status correction workflows: <strong>Condition Code 44</strong> (change inpatient to outpatient before discharge with UR committee involvement, physician concurrence, and patient notification via the updated <strong>MOON</strong> form) versus <strong>Part B billing/provider liable</strong> for cases discovered after discharge.

Newer rules allow certain <strong>appeals</strong> when patients are reclassified from inpatient to observation, requiring an additional <strong>Medicare Change of Status Notice</strong> alongside MOON. The session closes with denial prevention strategies, auditing short stays, recommended UM roles (including an appeals/audit specialist), and a “day-in-the-life” UM workflow.

Keywords

utilization management

utilization review

medical necessity

level of care

evidence-based criteria

InterQual

Milliman

interdisciplinary rounds

bedside assessment

Medicare Conditions of Participation

UR committee

physician advisor

inpatient status

observation status

two-midnight rule