Utilization Management Workshop Series: Best Practice Applications for the Hospital Setting Part 4-Utilization Management Series Part 4 Presentation

Utilization Management Series Part 4 Presentation

Pdf Summary

The document discusses utilization management catch-up, focusing on various aspects such as ED case management, physician collaboration, payer contracts, and a study guide. In ED case management, the purpose is to facilitate patient flow, expedite necessary care, and collaborate with interdisciplinary teams. Functions include timely care, discharge planning, and communication with providers. The job involves reviewing medical necessity, identifying readmissions, and collaborating with physicians. Physician collaboration is crucial for successful documentation and reimbursement, emphasizing real-time conversations and education. Payer contracts pose challenges due to varying reimbursement schedules and contract language. The study guide covers utilization review definitions and case studies on denial appeals and inpatient vs. observation services. It also delves into topics like the 2-midnight rule, physician peer-to-peer discussions with payers, and billing for observation hours. Strategies for handling medical necessity denials and ensuring appropriate care are highlighted, emphasizing clear communication, documentation, and appeals processes. The importance of physician collaboration, effective utilization management verbiage in contracts, and understanding payer criteria are emphasized throughout the document.

Keywords

utilization management catch-up

ED case management

physician collaboration

payer contracts

study guide

patient flow

discharge planning

medical necessity

reimbursement

documentation