Hospital Utilization Management Handbook: A Reference for Physician Advisors, Case Managers, and UR Professionals

The Definitive Working Guide to Hospital Utilization ManagementHospital utilization management sits at the intersection of clinical medicine, federal regulation, payer contracts, and hospital operations — and almost no one is formally trained for it before they are doing it. Physician advisors are handed the role mid-career. Case managers learn it on the worklist, under pressure. The CMS manuals run thousands of pages. The MAC bulletins contradict each other. The denials keep coming.This is the book that makes sense of it all.Written for the professionals who carry the daily work, this guide delivers what regulatory texts cannot: a single, working volume that explains what the rules are, why they exist, and how to apply them when the chart, the criteria, and the calendar do not agree.What's InsideAcross 15 focused chapters and 10 operational appendices:The Two-Midnight Rule, the case-by-case exception, and the Inpatient-Only ListStatus determinations, Condition Code 44, and the self-denial processThe five levels of Medicare appeals, plus commercial and Medicare Advantage frameworksInterQual and MCG — what they are, what they aren't, and how to argue both inside and outside themThe IM, MOON, HINNs, and ABN — every notification, every trigger, every timing requirementConditions of Participation (§482.30, §482.43) and the IMPACT ActIPPS, OPPS, MS-DRGs, APCs, and the financial impact of every status decisionRAC, MAC TPE, UPIC, OIG, DOJ audits and the False Claims ActLength-of-stay, GMLOS, avoidable days, and HRRP readmission strategySNF, IRF, LTACH, home health placement under modern coverage rulesBehavioral health, EMTALA, surgical admissions, and end-of-life casesBuilding, staffing, and leading a mature UM programPlus appendices: sample UR plan, physician advisor job description, notification chart, Two-Midnight decision tree, appeal letter templates, documentation templates, CMS citation reference, glossary, and index.Who This Book Is ForPhysician advisors, case managers, UR nurses, discharge planners, social workers, revenue cycle and appeals teams, CDI specialists, compliance officers, UM directors, VPs of Care Management, CMOs, and medical staff leaders.What You Will GainBy the time you finish this book, the language of UM will no longer be foreign. The Two-Midnight Rule will make sense as a framework for thinking. Notifications will stop blurring together. The appeals process will look like a process. You will know how to build defensible documentation, recognize the patterns that drive denials before they happen, and avoid the documentation patterns that produce False Claims Act exposure. You will have a working command of every procedural mechanism the discipline depends on — and practical templates you can adapt the day they arrive.The next time a difficult case lands on your worklist, you will know where to begin.Take Command of the WorkWhether you read it cover-to-cover or keep it on your desk for the next status question, the next appeal, the next survey — this is the book this discipline was missing.Scroll up and click "Buy Now" today. Read more