7:30 am
8:00 am
Christine C. Stallkamp
Christine C. Stallkamp, MD, FAAFP, CHCQM-PHYADV
System Director, Revenue Integrity and Care Coordination
Main Line Health

8:15 am

Dealing with appeals and denials can be a time consuming and costly task. Discuss the breakdown of appeal levels and determine when to pursue an appeal and when to call it quits.

  • Review the levels of appeal and the costs associated with each level
  • Identify instances when you should stop at a peer to peer or go to an ALJ
Jessica L. Gustafson
Jessica L. Gustafson, Esq.
Founding Shareholder
The Health Law Partners, P.C.

Abby Pendleton
Abby Pendleton, Esq.
Founding Shareholder
The Health Law Partners, P.C.

9:00 am

Siloes that exist between utilization management, case management, and disease management within a payer organization inhibit improvements in care delivery. Payers who integrate their services provide higher quality and more seamless care to their members. The utilization management team can provide leadership in these initiatives by taking a more active role in the medical management process.

  • Create communication sharing processes to facilitate seamless work between departments
  • Take a proactive approach to collaboration and leadership
  • Maintain communication with physician partners to prevent unnecessary readmissions
Patricia J. Jones
Patricia J. Jones, RN, BHSA, CCM, CPHQ
Vice President, Care4U, Georgia Market

10:15 am

CMS penalizes hospitals for high readmission rates, necessitating a growing focus on managing chronic conditions for which patients are readmitted. In this session, discuss how to engage the care team in a more effective case management strategy to improve care for patients with chronic conditions and better streamline care transitions.

  • Ensure plans of care are done efficiently and appropriately without delays, especially for complex cases
  • Build better relationships with SNFs and long term care facilities to improve transitions of care
  • Engage the care team to make sure that the right patients are getting the right care at the right time
Jenny Prescia
Jenny Prescia, MSN, RN, ACM, CCDS, NE-BC
Director, Case Management/Social Services/Orders Management Unit/RAC
Northwestern Lake Forest Hospital

Portia J. Zaire
Portia J. Zaire, MSNEd BSN RN-BC
Director, Clinical Nursing
Primary One Health

Prathima Setty
Prathima Setty, MD

11:00 am

Payers and providers must work together to improve quality and ensure that all are contributing to their quality mission. This includes working with clinical partners as well as their own clinicians to define and gain buy-in for value-based care. Discuss the challenges and “pain points” payers and providers face in creating more seamless collaboration and communication that generates high quality, value-based care.

  • Evaluate quality processes by acting on the metrics available to payers and providers
  • Nurture relationships between clinical hospital leadership and commercial payers
  • Determine how to focus on the case reviews that are most time-sensitive
  • Outline how to make an argument that a case does meet criteria, especially for high cost diagnoses
Joshuha Ayres
Joshuha Ayres
Manager, Utilization Management
University of Maryland Medical Center

David Goldner
David Goldner, MD, FACC
Medical Director, Utilization Management and Appeals
Lehigh Valley Health Network

Debra Jacobs
Debra Jacobs
Assistant Vice President, Utilization Management, Clinical Operations, Complaints & Grievances
UPMC Health Plan

Patricia J. Jones
Patricia J. Jones, RN, BHSA, CCM, CPHQ
Vice President, Care4U, Georgia Market

Shared with Health Plan Utilization Management Summit

12:00 pm