Compliance Measures For Case Management

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 then 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.

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 status from Medicare, so your compliance is critical to a good Joint Commission survey outcome. This program will help you to identify where you may have compliance practice gaps as well as how to fix them!

• 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.
• Your requirements to be compliant with the Important Message from Medicare.
• Explain how the patient choice lists are used.
• Understand the different types of HINNs and when they should be given.
• Document for compliance

• Compliance overview for case managers
• Balancing quality and cost
• The Conditions of Participation
• Compliance at the access points
• The 2-Midnight Rule and Observation
• The NOTICE Act
• The Important Message from Medicare
• The HINN
• Changes in Patient Choice
• Utilization management and compliance
• Documenting for compliance
• How to perform a compliance gap analysis
• Compliant UR Committee

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

• Director of Case Management
• Compliance Officer
• RN Case Managers
• Director of Quality Management
• Director of Social Work
• Social Workers
• Hospitalists
• Physician Advisor

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, educating case management professionals and assisting in implementation of case management departmental changes. 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. She was responsible for case management, social work, discharge planning, utilization management, denial management, bed management, the patient navigator program, the clinical documentation improvement program and systems process improvement. Dr. Cesta has also held positions as Corporate Vice President for Patient Flow Optimization and Director of Case Management. She 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.