Module B: External Forces

CE Credits: 1.75


This module looks at the outside entities and processes that shape the process of UM. It begins by looking at the various government and regulatory oversight organizations, including the Centers for Medicare & Medicaid Services (CMS) and The Joint Commission (TJC)— which oversee hospitals—and the National Committee for Quality Assurance (NCQA) and URAC (formerly referred to as the Utilization Review Accreditation Commission), which oversee health plans. Next, the module looks at how hospitals typically define medical necessity, and how hospital case managers can work with health plan case managers to agree on the best care for patients—from hospital stays to single case agreements (SCAs), which are used when an out-of-network provider delivers medically necessary emergency care. Last, the module details how oversight activities can minimize overpayments and underpayments for care.

Learning objectives: After completing this module case managers will be able to:
» Identify hospital UM regulatory and accrediting agencies
» Describe health plan UM regulatory and accrediting agencies
» Explain benefits of hospital and health plan coordination and communication
» Discuss the impact of oversight activities


Advance your professional practice: By understanding the various guidelines for authorizing care, CMs can acquire the most efficient and effective care for patients, and make the hospital less vulnerable to payment denials.

Improve organizational performance: Careful use of utilization management can have a significant effect on a hospital’s revenue cycle, since it can help us reduce costs, shorten stays, and prevent denials. When we understand the importance of the CM’s job, and support a commitment to UM, the whole team benefits.