HH

Part 1

Describe what utilization management is regarding benefits coverage. Identify the different categories and provide an example of each. Use first-hand experience if applicable.

Part 2

Your hospital has learned that patients with a diagnosis of congestive heart failure are being readmitted 28 percent of the time. You have received notification that CMS is no longer going to reimburse hospitals for readmissions within 30 days. Outline a strategy to tackle this quality program.