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

Toni Cesta

Toni Cesta

Toni Cesta, Ph.D., RN, FAAN is partner and health care consultant at Case Management Concepts, LLC, a consulting company which assists institutions in designing, implementing and evaluating acute care and community case management models and providing on-site education to case management staff, and strategies for assisting health care...
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Pre-recorded
60 Mins
Toni Cesta

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.  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.  You will learn whether 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.

Webinar Objectives


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 and remains an integral part of the work of the acute care case manager.

Are you up to date on the issues related to case management such as the Conditions of Participation from The Centers for Medicare and Medicaid Services?

Do you know the best practices in performing this key role? Perhaps you have only recently taken on this complex and key role for your hospital.

This program will review the role of utilization management as it applies to today’s contemporary case management models. Included will be best-practice suggestions for your practice with tips and strategies for stream-lining the process and making it as efficient as it can be.

Webinar Agenda


  • 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

Webinar Highlights


  • Review the conditions of Participation for Utilization Review
  • Discuss how clinical reviews relate to medical necessity
  • Understand the areas of compliance for utilization review and how to maintain compliance
  • Describe the three types of clinical reviews and how each is used.
  • Review the types of HINNs and how to properly use them
  • Discuss the 2 Midnight Rule, access point case management and utilization management.

Who Should Attend


  • RN Case Managers
  • Social Workers
  • Directors of Case Management
  • Directors of Social Work
  • Physician Advisors
  • Directors of Compliance
  • Director of Nursing
Event Registration
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$299.00
$199.00
$199.00
$299.00
$299.00
$199.00
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