Utilization and Denial Management for the Hospital Case Manager and Leader: Medical Necessity in the World Busy Case Managers and AI

Why Should You Attend:

Utilization management is a challenging process. Payers are demanding and are doing everything they can to deny payment through denial of medical necessity. Case management leaders struggle with determining the best model of case management, the optimal roles and the place that utilization management should reside—as a functional role of a bedside RN case manager or separate from that role.

Denial management requires critical thinking by RN case managers and can be time-consuming, as it can occur either during the hospital stay or after the patient has been discharged. Depending on the payer, there are specific rules and regulations that must be followed (for example, in the case of a traditional Medicare patient). These rules and regulations can be challenging to understand and to operationalize.

The case management leader must oversee this process and ensure each step of the process is followed, both timely and appropriately.

Areas Covered in the Webinar:

• Utilization Review Versus Utilization Management (UM)
• Case Management Roles in Utilization Management
• Rules and Regulations Affecting Utilization Management Processes
• The 2-Midnight Rule
• Hybrid Models of Utilization Management and Reimbursement
• Integrated Model of UM
• Triad Model of UM
• Prospective, Concurrent and Retrospective Review of Utilization Management
• Denial Management: Key Functions
• Steps in the UM Process Where Denials Can Occur
• Avoiding Denials: The Leader and the RN Case Manager
• Responding to Denials: The RN Case Manager and Appeals Coordinator
• Utilization Management’s Future: Artificial Intelligence
• Planning for the Future: The Leader and the RN Case Manager

Who Will Benefit:

• RN Case Managers
• Social Workers
• Utilization Managers
• Appeal Coordinators
• Directors of Case Management
• Directors of Utilization Management
• Directors of Social Work, Managers
• Supervisors of Case Management, Utilization Management and Social Work
• Executives to whom these leaders report

Beverly Cunningham
Consultant, Case Management Concepts LLC

Bev Cunningham, MS, RN, ACM is a founding partner of Case Management Concepts, LLC. She has a 25-year deep working knowledge of case management with specific expertise in denials management, patient flow and the role of the Case Manager and Social Worker in the Case Management process. Bev is also a certified case manager with the American Case Management Association. She has served as a Commissioner on the Commission for Case Management Certification and is a fellow with the Advisory Board. Bev is also the former Vice President of Resource Management at Medical City Dallas Hospital.

She has co-authored a book for hospital case managers—Core Skills for Hospital Case Managers and has written the utilization management chapter in the past two editions of CMSA’s book, Core Curriculum for Case management.

Topic Background:

Utilization management was the first role applied in acute care case management models. It was first known of as utilization review but has evolved into something much more comprehensive than that. Today it encompasses elements of resource management and denials management as well. Physicians, both the practicing physician and the physician advisor are often left out of this important process and must be included in any contemporary case management utilization management model. This webinar will review the role of utilization management as it applies to today’s contemporary case management models. The struggle to ensure adequate medical necessity evaluation that is aligned with the 4 roles of an RN case manager is real. Leaders are searching for adequate staffing to provide case management that can meet the optimal outcomes expected from hospital leaders.

Denials management, both concurrent and retrospective are critical in ensuring optimal reimbursement for the hospital. The role of the appeals coordinator and the impact this position can have in supporting the RN case manager on the unit will also be examined.

Some options have included outsourcing utilization management and separating the function of utilization management from the bedside RN case manager. These both set the scene for the challenge of siloed processes that do not meet the need of timely response and potential denials. The most recent option is the use of artificial intelligence that supports the utilization management function of the RN case manager. This is a very new process and will be discussed in this webinar to provide understanding for both the case management leader and RN case manager in considering this solution as a possible alternative.

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