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

Video Transcription

Video Summary

In Part Two of this webinar on case management and utilization management, Dr. Toni Sesta and Bev Cunningham, founding partners of Case Management Concepts, detailed the evolving complexities of compliance, regulations, and best practices in hospital case management. They emphasized four fundamental case management roles: utilization management, resource management, discharge and transition planning, and care coordination.<br /><br />A significant focus was the "two-midnight rule," which determines inpatient Medicare payments based on whether a hospital stay is expected to span at least two midnights, with thorough documentation required. Medicare Advantage plans now also adhere to this rule, though some modify reimbursement levels based on Milliman Care Guidelines. The speakers stressed the importance of urgent, daily case reviews—particularly for Medicare beneficiaries in observation status exceeding 24 hours—to determine appropriate patient status adjustments. Observation services criteria and their application post-ambulatory surgery were discussed, noting that observation orders issued pre-surgery are generally non-compliant.<br /><br />The presenters highlighted regulatory requirements including CMS Conditions of Participation and the necessity of a Utilization Review (UR) committee. They underlined the critical role of physician advisors in peer reviewing utilization decisions, particularly for short inpatient stays failing medical necessity criteria. Processes for managing denials, appeals, and patient notifications such as the Medicare Outpatient Observation Notice (MOON) and the Medicare Change of Status Notice (MCSN) were described, including patient rights to appeals.<br /><br />Further, the session covered compliance roles within case management departments, recommending specialized roles such as denial/appeal specialists and observation service case managers to optimize outcomes. Leadership's responsibility to maintain compliance, review contracts, and educate staff was emphasized. Lastly, resources and guidance documents were shared for continued learning. The session concluded with Q&A addressing documentation and regulatory nuances, reinforcing the need for ongoing attention to detail in utilization management.

Keywords

case management

utilization management

hospital compliance

two-midnight rule

Medicare payments

Medicare Advantage

Milliman Care Guidelines

observation status

discharge planning

care coordination

CMS Conditions of Participation

Utilization Review committee

physician advisors

denials and appeals

Medicare Outpatient Observation Notice