The Hospital Guide to Contemporary Utilization Review
The Hospital Guide to Contemporary Utilization Review

Author: Stefani Daniels

Publisher:

Published: 2015-04-16

Total Pages: 0

ISBN-13: 9781556452147

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The Hospital Guide to Contemporary Utilization Review is a comprehensive resource designed to identify utilization review (UR) best practices and provide guidance on developing and enhancing a contemporary UR committee. This book focuses on the latest UR and patient status requirements to help hospitals perform high-quality reviews and comply with regulations. The book covers a range of topics, including compliance with the UR Condition of Participation, legal obligations of a hospital, contract language, and compliant UR plan language to provide an understanding of the expectations of a UR program. Tips for intradepartmental collaboration are included to guide professionals through the process of selecting a physician advisor and partnering with nurses, case managers, and revenue cycle team members. This book will help you do the following: Identify the components of a best practice hospital utilization review (UR) program Describe the legal obligations of the hospital to comply with chapter 42 CFR 482.30 of the Conditions of Participation (CoP) Use the publication as a tool to assess his or her own hospital's UR processes Summarize the benefits of a dedicated UR team to promote compliance with the CoP Facilitate the development of a contemporary UR committee Assess an organization's opportunities to improve processes to benefit patient care and hospital success Recommend compliant language for the organization's UR plan Construct commercial contract language, in collaboration with the organization's contract manager, that promotes a partnership to ensure appropriate use of acute care resources Seek out operational resources to perform high-quality reviews that fully comply with the CoP Explain the connection between a good utilization review plan and the hospital revenue cycle initiatives

The Hospital Guide to Contemporary Utilization Review, Third Edition
The Hospital Guide to Contemporary Utilization Review, Third Edition

Author: Stefani Daniels

Publisher:

Published: 2021-10

Total Pages: 194

ISBN-13: 9781645351382

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The Hospital Guide to Contemporary Utilization Review, Third Edition, is a comprehensive resource designed to identify utilization review (UR) best practices and provide guidance on developing and enhancing a contemporary UR committee. This book focuses on the latest UR and patient status requirements to help hospitals perform high-quality reviews and comply with regulations in a value-based world. The book covers a range of topics, including compliance with the UR Conditions of Participation (CoP), legal obligations of a hospital, contract language, and compliant UR plan language, to provide an understanding of the expectations of a UR program. Tips for intradepartmental collaboration are included to guide professionals through the process of selecting a physician advisor and partnering with nurses, case managers, and revenue cycle team members. This book will help you do the following: Identify the components of a best-practice hospital UR program Describe the legal obligations of the hospital to comply with Chapter 42 CFR 482.30 of the CoP Use the publication as a tool to assess your own hospital's UR processes Summarize the benefits of a dedicated UR team to promote compliance with the CoP Differentiate between traditional Medicare and Medicare Advantage Facilitate the development of a contemporary UR committee Discuss the pros and cons of the possible reporting structures for UR activities Examine the role of the physician advisor as a member of the UR team Recognize the crucial role of revenue cycle in the work of the UR specialist Recommend compliant language for your organization's UR plan Describe the components of the revenue cycle pertinent to UR Differentiate inpatient and outpatient payment rules Explain the basics of claim preparation Review physician billing and payment rules Differentiate between national coverage determinations, local coverage determinations, and commercial payer criteria Seek out operational resources to perform high-quality reviews that fully comply with the CoP Explain the connection between a good UR plan and a hospital's revenue cycle initiatives

CMSA Core Curriculum for Case Management
CMSA Core Curriculum for Case Management

Author: Hussein M. Tahan

Publisher: Lippincott Williams & Wilkins

Published: 2016-07-05

Total Pages: 862

ISBN-13: 1496351894

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The fully updated CMSA Core Curriculum for Case Management, 3rd edition, is the definitive roadmap to an informed, effective, collaborative case management practice. This comprehensive, expertly-written guide provides those directly or indirectly involved in case management with information about best practices, descriptions of key terms, essential skills, and tools that fulfill the current Case Management Society of America’s (CMSA) standards and requirements. Addressing the full spectrum of healthcare professional roles and environments, this is both a crucial certification study guide and vital clinical resource for the case management professionals in all specialty areas, from students to veteran case managers. This unique resource provides the core knowledge needed for safe, cost-effective case management with the following features ... NEW text boxes highlighting key information and vital practices in each chapter NEW and updated Standards of Practice implications in each chapter NEW and updated content on transitions of care, community-based care, care coordination, Value-Based Purchasing, ethics and social media, the impacts of health care reform, and digital technology NEW and updated content on accreditation in case management NEW chapter that lists key additional resources, by topic Official publication of the Case Management Society of America, connecting CMSA core curriculum to current CMSA Standards of Practice Easy-to-grasp, detailed topical outline format for quick scan of topics Complete, updated core knowledge required of case managers, with expert descriptions and direction on areas including: Case management roles, functions, tools, and processes Plans, clinical pathways, and use of technology Transitional planning Utilization management and resource management Leadership skills and concepts Quality and outcomes management; legal and ethical issues Education, training, and certification Health care insurance, benefits, and reimbursement systems Practice settings and throughput Interdisciplinary teams’ needs in: hospitals, community clinics, private practice, acute care, home care, long-term care and rehab settings, palliative care, and hospice settings Up-to-date guidance on case management specialty practices, including: nursing, life care planning, workers’ compensation, disability management, care of the elderly, behavioral health, transitions of care, subacute and long-term care, utilization review/management, primary care and medical/health home, and more Essential content for academic reference, training, certification study, case management models design, performance or program evaluation

The Respiratory Therapist as Disease Manager
The Respiratory Therapist as Disease Manager

Author: Harry R Leen

Publisher: Jones & Bartlett Learning

Published: 2019-12-02

Total Pages: 207

ISBN-13: 1284168956

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Written for both students and practicing clinicians, The Respiratory Therapist as Disease Manager is a foundational resource for the Respiratory Therapist who desires to augment their acute care and technical skills with a knowledge base that will enable them to competently perform the duties of a Pulmonary Disease Manager.

Effective Peer Review
Effective Peer Review

Author: Robert J. Marder

Publisher: HC Pro, Inc.

Published: 2007

Total Pages: 191

ISBN-13: 1601460112

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HCPro is pleased to introduce Effective Peer Review: A Practical Guide to Contemporary Design, Second Edition, authored by The Greeley Company experts, Robert J. Marder, MD and Mark A. Smith, MD, MBA, FACS. Completely updated to help you: * Comply with The Joint Commission's 2007 standards * Deliver focused and ongoing professional practice evaluations * Evaluate physician core competencies * And much more! Peer review continues to rate as a top problematic issue and one you can't ignore. The pressure is driven by publicly available national data, The Joint Commission's 2007 standards expanding measurement of physician competence, and hospital boards' need to be assured that the peer review process is functioning effectively. Learn how to go beyond just satisfying a regulatory requirement to performing peer review that fosters true improvement within your facility. Although hospitals go through the motions of peer review, they are often unable to make it a meaningful process-one that results in true improvement in physician performance and meets The Joint Commission's standards. Transform your peer review process and meet external requirements with Effective Peer Review: A Practical Guide to Contemporary Design, Second Edition. Get best practices to make peer review worthwhile Newly updated and in high demand, Effective Peer Review, Second Edition, outlines and provides advice about how to do physician peer review effectively. Authored by experts from The Greeley Company, this book and CD-ROM goes beyond just reviewing the Joint Commission standards. It puts the standards in context by emphasizing best practices you can implement in your peer review process. Plus, you'll receive thorough discussion about data analysis and collection, along with peer review scoring and rating systems. Critical information at your fingertips Offering step-by-step guidance to peer review, this book and CD-ROM will help you: * Streamline your exist

The Economic Evolution of American Health Care
The Economic Evolution of American Health Care

Author: David Dranove

Publisher: Princeton University Press

Published: 2009-01-10

Total Pages: 220

ISBN-13: 1400824680

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The American health care industry has undergone such dizzying transformations since the 1960s that many patients have lost confidence in a system they find too impersonal and ineffectual. Is their distrust justified and can confidence be restored? David Dranove, a leading health care economist, tackles these and other key questions in the first major economic and historical investigation of the field. Focusing on the doctor-patient relationship, he begins with the era of the independently practicing physician--epitomized by Marcus Welby, the beloved father figure/doctor in the 1960s television show of the same name--who disappeared with the growth of managed care. Dranove guides consumers in understanding the rapid developments of the health care industry and offers timely policy recommendations for reforming managed care as well as advice for patients making health care decisions. The book covers everything from start-up troubles with the first managed care organizations to attempts at government regulation to the mergers and quality control issues facing MCOs today. It also reflects on how difficult it is for patients to shop for medical care. Up until the 1970s, patients looked to autonomous physicians for recommendations on procedures and hospitals--a process that relied more on the patient's trust of the physician than on facts, and resulted in skyrocketing medical costs. Newly emerging MCOs have tried to solve the shopping problem by tracking the performance of care providers while obtaining discounts for their clients. Many observers accuse MCOs of caring more about cost than quality, and argue for government regulation. Dranove, however, believes that market forces can eventually achieve quality care and cost control. But first, MCOs must improve their ways of measuring provider performance, medical records must be made more complete and accessible (a task that need not compromise patient confidentiality), and patients must be willing to seek and act on information about the best care available. Dranove argues that patients can regain confidence in the medical system, and even come to trust MCOs, but they will need to rely on both their individual doctors and their own consumer awareness.

CMSA Core Curriculum for Case Management
CMSA Core Curriculum for Case Management

Author:

Publisher: Lippincott Williams & Wilkins

Published: 2008

Total Pages: 666

ISBN-13: 9780781779173

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This text contains the core body of knowledge for case management practice as delineated by the Case Management Society of America (CMSA), the largest professional organization of case managers. The core curriculum provides a "synthesis of case management evolution," and presents essential elements, concepts, and vision for current and future case management practice. This edition is significantly expanded to reflect the dynamic changes taking place in case management. Each chapter is organized in a consistent format that includes learning objectives; introduction; important terms and concepts; key definitions; and references.