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Utilization Management: Rules, Regulations and How-To’s
Recorded Webinar
The Centers for Medicare and Medicaid Services (CMS) provides us with two Conditions of Participation that apply to the work of case management professionals. These include the Conditions of Participation for Discharge Planning and the Conditions of Participation for Utilization Review. This webinar will focus on these rules as they apply to the role of utilization review. In order for case management departments to be compliant with these regulations, RN and social work case managers must understand these ‘rules of the road’ for utilization review and work within their boundaries.
In this jam-packed program you will learn how to stream-line your utilization management process as well as understand the Conditions of Participation for Utilization Review and how they impact on your work as a case manager. We will discuss the differences between utilization review and utilization management. The process for incorporating medical necessity into the process of utilization management will be explained. This will be followed by a discussion of the compliance components for utilization review including the utilization management plan, the utilization management committee, Condition Code 44, and the two-midnight rule. How to incorporate the two-midnight rule into your utilization management process. Also explained will be the various types of clinical reviews performed by the case manager.
The various types of Hospital-Issued Notices of Non-Coverage (HINNs) will be described with examples of how they are used. You will learn whether or not your utilization management committee is effective and compliant.
Venue: Recorded Webinar
Areas Covered A major component of successful revenue management is accurate charging for services provided. Charges must be identified, posted timely and completely. Hospital charge capture is typically handled by the department that provided the service. Professional charges may be posted by the provider. In either case, the function may be a low administrative priority with little to limited training for charging activities. Coordination between departments may not be established. Accountability for correct charging may be minimal. There may be no formal policies or baseline controls for correct charge capture. Different systems may be used for charging and reconciliation An effective charge audit can identify lost revenue opportunities Webinar’s Goals Understand the importance of accurate charge capture Tips for charge review Departmental charge capture errors & omissions Revenue leakage resulting from charging errors Reduce non-compliance exposure Improvement of operational efficiency Enhance patient satisfaction Key Points Why Errors Occur Multiple departments entering charges Charge master may be incorrect or incomplete Error in number of units selected Error in item selection Inactive charge New service not added Incorrect revenue code/cost center System conversions Overreliance on claims scrubber Target Audience Physicians Practice managers Medical assistants Nurses Compliance staff Billers Coders Revenue Cycle Risk Management
A hospital chargemaster is a comprehensive list of a hospital's products, procedures, and services. Everything from prescription drugs to supplies for diagnostic tests has a unique price listing in the chargemaster. Major components include revenue codes that reflect the site of service and applicable CPT/HCPCS codes that indicate the service provided/charged. Poor matches between these code sets may lead to distorted cost centers, lost revenue, charges bundled that should be separately reported and incomplete departmental charging. Webinar’s Goals Understand chargemaster code functions Understand revenue leakage resulting from poor chargemaster structure Understand why correct departmental charging is vital to revenue integrity Appropriate training for charge entry staff Billing attention to posted charges Who Should Attend Chargemaster Maintenance Staff Compliance staff Billers Coders Revenue Cycle Managers & Staff Risk Management Charge entry staff
Clinical documentation is the cornerstone for all patient medical records. This information should be of the highest quality to allow for optimal patient outcomes as well as supporting research, medical coding and other uses of the medical record. Its purpose is to adequately relate the patient’s current and historical conditions and treatments with primary focus placed on situations that affect the current medical encounter. It also supports the provider’s defense should the case become a legal issue. Webinar’s Goals Review of 7 criteria that all entries in the medical record should include Impact of documentation on coding & claims Establishing a CDI team Significance of abnormal lab results: querying the provider. Measurement of lesions, when taken and inclusion of margins. Why it matters & how reimbursement may be affected. Start & stop times & methodology for infusions & discrepancies in billing. Complete reporting for administration and substance. Diagnostic testing and medications should be supported in a diagnosis. Unsupported documentation may cost you money. Depth of wounds and cause should be clear. Clarity needed for both depth and origin of wound. Severity of illness. Hospitals and payers are increasingly scrutinizing patient severity. Lack of detail costs money. Diagnosis present on admission? Certain conditions do not generate additional revenue if occurrence after admission. Areas Covered The ICD-10 code set requires explicit documentation of conditions & treatments in order to support the severity of patients under treatment as well as allow for the significant specificity required by this code set. Ambiguous documentation and generic coding will no longer guarantee reimbursement and may generate a claims denial for lack of medical necessity. In this session, we will review the theory of high-quality clinical documentation which has the support of healthcare regulatory guidelines and peer-review research. Additional consideration involves medical outcomes that may result in legal action. When clinical documentation is vague, missing key elements and conflicting statements, the provider may find that he/she is handicapped in supporting medical decisions and patient results, particularly when the result is a negative outcome for the patient. In today’s healthcare environment, many patients have become educated consumers of medical services. They are more inclined to request their own medical record, carefully review explanation of benefits from payers, and request a review of any information they deem to be incomplete or questionable. Target Audience Coding Billing Revenue Cycle Physicians Mid-level providers Nurses Claims follow-up Compliance Auditors
Elevate your Excel prowess with this training. Aimed at users already versed in Excel's core functions (SUM, X/VLOOKUP, COUNTIF etc), this course introduces users to some of the new innovative functions added since 2020, exclusively available to Microsoft 365 and Excel 2021 users. These cutting-edge tools are designed to streamline your formula creation process, enhance your data interaction, and expand your analytical capabilities. Embrace the simplicity of extracting unique values, sorting and filtering datasets, creating dynamic, self-updating lists and much more! Whether you’re looking to improve efficiency, accuracy, or both, these features will set you on a path to becoming an Excel ninja. Ensure your skill set remains at the forefront of technological advancements with these essential, transformative functions that redefine what's possible in Excel. Topics We’ll Explore UNIQUE: Extract distinct values effortlessly FILTER: Refine your data with precision SEQUENCE: Generate ordered lists automatically SORT & SORTBY: Arrange your data with ease CHOOSECOLS & CHOOSEROWS: Select specific data segments TEXSPLIT, TEXTBEFORE, and TEXTAFTER: Manipulate text data like never before VSTACK: Merge arrays vertically with simplicity Who Should Attend? This intermediate-level training is tailored for Excel users eager to learn the cutting-edge functions exclusive to Microsoft 365 subscribers and Excel 2021 users. Prior to attending, confirm with your IT department whether your subscription includes these features.