Conference Materials (Password Required)

Case managers and social workers need to maintain compliance in several areas directly related to utilization management and discharge planning. Both the Joint Commission (and other regulatory bodies) and the Centers for Medicare and Medicaid Services (CMS) are auditing hospitals and case management departments for compliance with the Conditions of Participation and other regulatory requirements. Every case management professional needs to know how these requirements impact their professional practice.

This program will review the compliance issues that most greatly impact your practice such as the 2-midnight Rule, the NOTICE Act, HINNs, The Important Message, and others. The Joint Commission is now monitoring these issues when they have deemed the status of Medicare, so your compliance is critical to a good Joint Commission survey outcome.  This program will help you identify where you may have compliance practice gaps and how to fix them!

As case managers, we must be aware of the myriad of compliance issues that we must adhere to in our daily practice.  Never has this been more important to our work as case managers than it is now.  Our ability to remain compliant has become an element of audits from accrediting bodies such as the Joint Commission as well as the Centers for Medicare and Medicaid Services (CMS).  It is the right thing to do for patients as well.

By attending this session you will be able to ensure that you understand the compliance issues directly related to the practice of case management and that you have incorporated them into your daily practice. Compliance includes documentation and communication with the patient and family as well.  Be sure that your processes are hard-wired and part of your daily routine.

Learning Objective:

• Understand the compliance issues required under the Conditions of Participation for Utilization Management and Discharge Planning.
• Describe your responsibilities as they relate to Observation and the 2-Midnight Rule.
• Review your requirements to be compliant with the Important Message from Medicare.
• Explain how the patient choice lists are used.
• Understand the different types of things and when they should be given.
• Learned how to document for compliance.
• Understand the important role of social work and RN case managers in maintaining their professional compliance.

Areas Covered in the Session:

• Definition of compliance
• Definition of fraud
• Agencies requiring compliance
• Hospital processes and penalties
• Case management processes related to billing
• Ensuring payment
• Medical necessity and billing rules
• Conditions of Participation for Utilization Review and Discharge Planning
• Condition Code 44
• Provider Liable billing
• The 2 Midnight Rule
• Observation Status
• Hospital Issues Notices of Non-Coverage by Type
• Observation Status
• Patient choice
• 3-Day Qualifying Stay
• NOTICE Act

Suggested Attendees:

• RN Case Managers
• Social Workers
• Vice Presidents of Operations
• Director of Case Management
• Case Managers
• Directors and Vice Presidents of Nursing
• Directors of Patient Flow
• Director of Revenue Cycle
• Chief Financial Officers
• Chief Operations Officers
• Chief Medical Officer
• Hospitalists
• Director of Quality Management
• Nursing Home Directors
• Director of Home Care
• Director of Finance
• Case Managers
• Social Workers
• Vice President of Case Management
• Hospitalists
• Physician Advisors
• Directors of Social Work
• Compliance Officer

Presenter Biography:

Toni G. Cesta, Ph.D., RN, FAAN is Partner and Health Care Consultant in Case Management Concepts, LLC, a consulting company that 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.

Before 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. Before her position as Senior Vice President at Lutheran Medical Center, Dr. Cesta held positions as Corporate Vice President for Patient Flow Optimization at the North Shore – Long Island Jewish Health System and Director of Case Management, at 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.

Snippet From Our Previous Session