CMS Hospital CoP UR Planning Standards Updates

Are you prepared to comply all regulations for Utilization Review (UR)? Preventing unnecessary readmissions is essential. Hospitals that have a higher rate of readmission now receive less money from CMS. This is why there is increased surveillance activity in the area of discharge planning.

This program will cover the CMS (Center for Medicare and Medicaid Services) hospital Conditions of Participation regulations for Utilization Review. Every hospital that accepts Medicare and Medicaid reimbursement must be compliance with these standards. Compliance with the UR standards is more important to avoid penalties from the Recovery Audit Contractors (RACs) and other organizations such as the OIG.

It is important to establish medical necessity especially in light of the RAC program so hospitals don't have to pay back money. So what’s in your UR plan? This webinar covers what is typically found in a UR plan. It will discuss why hospitals get cited by CMS. Information will be provided about the deficiency reports. It will cover the new website to get the CMS manuals and the new email address for sending questions directly to CMS.

Does your hospital have a contract with your state QIO? Is there concise documenting in the chart regarding medical necessity and compliance with the two midnight rule? In this program, hospital & compliance expert Sue Dill Calloway, will discuss the MOON form required for outpatient observation patients which is revised along with revisions to the detailed notice and IM notice. Learn what is new.

Session Agenda

  • Utilization Review under Tag 652

  • How to keep up with CMS changes in the future

  • How to locate a copy of the CMS UR Requirements

  • Last changes regarding accreditation organizations assessing compliance with UR standard

  • 3 tag number revisions

  • CMS revised many of the discharge planning requirements

  • Revised email to ask questions and to get all manuals

  • CMS deficiency reports and why hospitals get cited

  • UR plan required - Must include review of services provided to Medicare and Medicaid patient

  • Joint Commission adds UR plan and committee standard

  • If QIO contract, surveyor will not assess remainder of UR standards

  • UR plan requirements, Goals of a UR plan, and Activities performed in UR plan

  • Functions of a UR committee - Choosing Wisely and Manage Wisely, Conflicts of interest

  • Agreement with QIO ; BFCC QIOs

  • State UR procedures; Composition of UR Committee

  • MOON Forms for outpatient observation patients

  • Moon form, IM notice and detailed notice revised

  • Review of physicians and non-physician providers

  • Frequency of reviews ; Scope of reviews

  • Observation verses inpatient admission

  • Admissions or continued stay

  • Medical necessity and Medical necessity determination

  • RACs and medical necessity

  • Non-physician determinations

  • The two midnight rule

  • Discharge screens, and Intensity of services

  • Documentation of the decision making process

  • MOON form and new changes to the IM and detailed notice

Session Objectives

  • Recall that the hospital must have a UR plan, and Recall there are three revised tag numbers

  • Discuss the importance of documentation of medical necessity by the physician in the medical record

  • Describe that hospitals are required to have a UR Committee

Who Should Attend?

  • Case managers, Utilization Review committee, Transitional care nurses, Social workers, Discharge planners

  • Compliance officer, Risk manager, Regulatory officer, Joint Commission coordinator

  • Physician advisor, UR nurses, Nurse educators, Nurses with direct patient care, Health information director

  • Chief medical officer, Chief operating officer, Chief executive officer, Chief nursing officer

  • Business office manager, Billing office director,  All nursing directors and managers,  and

  • Anyone else involved with the UR process and comply with the standards

Ask a question at the Q&A session following the live event and get advice unique to your situation, directly from our expert speaker.

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Webinar Information

Date / Time : 26 Mar 2020 @ 01:00 PM EST

Duration : 120 Minutes

Number Of Attendees

Avail Discount At Checkout

For Group Registration
Contact 1888-437-7218 or
Email us at

Speaker Detail

Sue Dill Calloway RN, Esq. CPRHM CCMSCP AD, BSN, MSN, JD

Alt Text Sue Dill Calloway, R.N., M.S.N, J.D. is a nurse attorney and President of Patient Safety and Healthcare Consulting and Education. She is also the past Chief Learning Officer for the Emergency Medicine Patient Safety Foundation and a board member. She was a director for risk management and patient safety for readmore...


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Webinar Information

Date / Time : 26 Mar 2020 @ 01:00 PM EST

Duration : 120 Minutes

Number Of Attendees

Avail Discount At Checkout

For Group Registration
Contact 1888-437-7218 or
Email us at