Fundamentals of Utilization Management: A Review of the Conditions of Participation for Utilization Review

Instructor: Toni Cesta
Product ID: 706359
Training Level: Basic
  • Duration: 60 Min
Attend this webinar to learn how to stream-line your utilization management process and understand the Conditions of Participation for Utilization Review and how they impact on your work as a case manager.
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Why Should You Attend:

In this jam-packed program 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, the various types of clinical reviews performed by the case manager will be explained.

You will learn whether or not your utilization management committee is effective and compliant.

The various types of Hospital-Issued Notices of Non-Coverage (HINNs) will be described with examples of how they are used.

You will learn strategies for passing a survey on the Conditions of Examples of utilization review committee reports will round out this comprehensive program.

Areas Covered in the Webinar:

  • The differences between utilization review and utilization management
  • The definition of medical necessity
  • How to balance financial and clinical medical necessity
  • Compliance as it relates to utilization management
  • Conditions of participation for utilization review
  • Components of a compliant utilization review plan
  • Components of a compliant utilization review committee
  • Condition Code 44
  • Provider Liable
  • Guidelines for utilization review surveys
  • Guidelines for admission and continued stays
  • Clinical aspects affecting medical necessity
  • Three types of utilization management
  • Utilization management and access point case management
  • Sample utilization management reports
  • The two-midnight rule and utilization management
  • Hospital Issued Notices of Non-Coverage – HINNs
  • Denial management as a component of utilization management

Who Will Benefit:

  • RN Case Managers
  • Social Workers
  • Directors of Case Management
  • Directors of Social Work
  • Physician Advisors
  • Directors of Compliance
  • Director of Nursing
Instructor Profile:
Toni Cesta

Toni Cesta
Consultant and Owner, Case Management Concepts LLC

Toni G. Cesta, Ph.D., RN, FAAN is Partner and Health Care Consultant in Case Management Concepts, LLC, a consulting company which assists institutions in designing, implementing and evaluating acute care and community case management models, new documentation systems, and other strategies for improving care and reducing cost. The author of nine books, and a frequently sought after speaker, lecturer and consultant, Dr. Cesta is considered one of the primary thought leaders in the field of case management.

Dr. Cesta writes a monthly column called “Case Management Insider” in the Hospital Case Management journal in which she shares insights and information on current issues and trends in case management.

Prior to her current work as a case management consultant, Dr. Cesta was Senior Vice President – Operational Efficiency and Capacity Management at Lutheran Medical Center in Brooklyn, New York. She was responsible for case management, social work, discharge planning, utilization management, denial management, bed management, the patient navigator program, the clinical documentation improvement program and systems process improvement. Prior to her position as Senior Vice President at Lutheran Medical Center, Dr. Cesta has held positions as Corporate Vice President for Patient Flow Optimization at the North Shore – Long Island Jewish Health System and Director of Case Management, Saint Vincents Catholic Medical Centers of New York, in New York City and also designed and implemented a Master’s of Nursing in Case Management Program and Post-Master’s Certificate Program in Case Management at Pace University in Pleasantville, New York. Dr. Cesta completed seven years as a Commissioner for the Commission for Case Manager Certification.

Dr. Cesta has been active in the research and development of case management for over 25 years. Her research in case management has included two funded studies measuring the effects of a case management model on congestive heart failure and fractured hip patient populations, with measures of patient satisfaction, quality of life, and short and long term clinical perceptions and outcomes.

Dr. Cesta has presented topics on case management at national and international conferences and workshops. Her books include “Nursing Case Management: From Essentials to Advanced Practice Applications”, “The Case Manager’s Survival Guide: Winning Strategies in the New Healthcare Environment”, “The Case Manager’s Survival Guide: Winning Strategies for Clinical Practice”, “Survival Strategies for Nurses in Managed Care” and “Core Skills for Hospital Case Managers”. Dr. Cesta is Consulting Editor of “Hospital Case Management Journal” and “Discharge Planning Advisor”. In addition, she serves as editorial advisory board member of several case management journals and publications including “Strategies for Healthcare Excellence” and “The Journal of Care Management”.

Dr. Cesta has a BS in Biology from Wagner College, a BS in Nursing from Adelphi University, an MA in Nursing Administration from New York University, and a Ph.D. in Nursing Research and Theory Development from New York University.

Dr. Cesta is a Fellow of the American Academy of Nursing. Among her awards are included the “Nursing Service Administration Award” from the New York State Nurses Association, the Jessie M. Scott Award for excellence in research, practice and education from the American Nurses Association, and three “Book of the Year” awards from the American Journal of Nursing. In 2010, she was awarded the Brooklyn Leaders Award from the Arthritis Foundation.

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