CMS Conditions of Participation for Utilization Management


Format: Live Webinar
Presenter: Toni G. Cesta, PhD., RN, FAAN
Event Date: 12/01/2020
Time: 1 pm ET | 12 pm CT | 11 am MT | 10 am PT
Duration: 60 Minutes



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 and 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.

 In this session, participants 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.

Learning Objectives:

  1. Understand the definition of medical necessity
  2. Review the utilization management components of the Conditions of Participation
  3. Discuss the Condition Code 44 process and your role
  4. Describe the different types of HINNs (Hospital Issues Notices of Non-Coverage) and when to use them
  5. Learn how the compliance components of utilization review
  6. Relate the components of utilization management to denial management
  7. Review the different types of clinical reviews

Areas Covered in the Session:

  1. The differences between utilization review and utilization management
  2. The definition of medical necessity
  3. How to balance financial and clinical medical necessity
  4. Compliance as it relates to utilization management
  5. Conditions of participation for utilization review
  6. Components of a compliant utilization review plan
  7. Components of a compliant utilization review committee
  8. Condition Code 44
  9. Provider Liable
  10. Guidelines for utilization review surveys
  11. Guidelines for admission and continued stays
  12. Clinical aspects affecting medical necessity
  13. Three types of utilization management
  14. Utilization management and access point case management
  15. Sample utilization management reports
  16. The two-midnight rule and utilization management
  17. Hospital Issued Notices of Non-Coverage – HINNs
  18. Denial management as a component of utilization management
Other Related Webinars:

Suggested Attendees:

  1. Physician
  2. Director of Case Management
  3. Director of Compliance
  4. Case Managers
  5. Social Workers
  6. Vice President of Case Management
  7. Directors of Patient Centered Medical Homes
  8. Home Care Directors and Managers
  9. Home Care Case Managers
  10. Community-Based Providers
  11. Directors of Nursing
  12. Directors of Ambulatory Programs
  13. Directors of Quality
  14. Directors of Finance

About the Presenter:

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, provides education on case management and related topics, and on-site assistance to case management departments.

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. 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.

After Registration

You will receive an email with login information and handouts (presentation slides) that you can print and share to all participants at your location.

System Requirement

Operating System: Windows any version preferably above Windows Vista & Mac any version above OS X 10.6
Internet Speed: Preferably above 1 MBPS
Headset: Any decent headset and microphone which can be used to talk and hear clearly

Can’t Listen Live?
No problem. You can get access to On-Demand webinar. Use it as a training tool at your convenience.

For more information you can reach out to below contact:
Toll-Free No: 1-302-444-0162