Part Two: Utilization Management Workshop Series: Best Practice Applications for the Hospital Setting (ODPT2W5039)-Utilization Management Workshop Series, Part 2 Presentation

Utilization Management Workshop Series, Part 2 Presentation

Pdf Summary

This presentation from the Georgia Hospital Association, led by Bev Cunningham and Toni Cesta, focuses on the critical rules and regulations impacting hospital utilization management (UM) in case management practice.<br /><br />Key topics include the four roles of case management—utilization management, resource management, care coordination, and discharge/transition planning—with a strong emphasis on UM, which actively ensures medical necessity and appropriateness of care.<br /><br />A central feature is the Medicare 2-Midnight Rule, effective January 1, 2024 for both traditional Medicare and Medicare Advantage patients. This rule requires that inpatient admissions generally span at least two midnights to qualify for Medicare Part A payment, backed by physician documentation. Observation services apply when stays are expected to be less than two midnights, with reassessment required after one midnight to determine if transition to inpatient admission or discharge is appropriate.<br /><br />Exceptions to the 2-Midnight Rule include unforeseen circumstances such as death, transfers, or election of hospice care. Case managers play a vital role in reassessing patients and collaborating with physicians on appropriate patient status, documentation, and billing, including use of Condition Code 44 for changes from inpatient to outpatient status.<br /><br />The presentation also outlines compliance shared responsibilities across hospital access points, emphasizing the importance of UM integration in various settings such as ED, surgery, and observation units. It covers Medicare Conditions of Participation, utilization review committee requirements, and medical necessity review processes with physician advisor involvement.<br /><br />Additional CMS-related patient notices are highlighted, including the Medicare Outpatient Observation Notice (MOON), Hospital Issued Notice of Noncoverage (HINN), Advance Beneficiary Notice (ABN), and Medicare Change of Status Notice (MCSN), along with patient rights to appeal status changes.<br /><br />Overall, this session stresses comprehensive education, interdisciplinary collaboration, consistent application of regulatory requirements, and proactive case manager roles to ensure compliance, proper billing, and quality patient care in hospital utilization management.

Keywords

Georgia Hospital Association

case management

utilization management

Medicare 2-Midnight Rule

inpatient admissions

observation services

Condition Code 44

Medicare Conditions of Participation

patient status documentation

hospital compliance