Overview

The hospital utilization management environment of 2026 is the most complex it has ever been. The Two-Midnight Rule now governs Medicare Advantage. The Inpatient-Only list is being phased out. New payer policies - Aetna's Level of Severity, Blue Cross NC's status reforms, UnitedHealthcare's Optum routing - are reshaping how denials reach the hospital and how appeals must be pursued. Patient notice forms transitioned in waves through the spring of 2026. Artificial intelligence now sits at the center of payer prior authorization, and the litigation around it is just beginning. Hospital Utilization Management: A Casebook is the practical, regulation-current guide physician advisors and case managers have been waiting for. Written by a practicing physician advisor, this book combines clear regulatory analysis with sixteen real-world case scenarios drawn from daily UM practice - each walking through the patient vignette, the status question, the case manager's review, the physician advisor's analysis, the decision and documentation, the common pitfalls, and the specific regulatory citations that govern the case. Inside, you'll find: A complete walkthrough of the Two-Midnight Rule in traditional Medicare and Medicare Advantage Operational guidance for the post-Inpatient-Only-list era, including the SNF three-day rule interaction Plain-language analysis of every major 2026 patient notice form and transition deadline Three peer-to-peer conversation scripts, ready to adapt for traditional Medicare, MA, and commercial payer denials The five sentences every admission note should contain, and severity-of-illness markers for the eight most common medical admissions A status decision tree, regulatory citations index, glossary, and sample UR plan language compliant with 42 CFR §482.30 Whether you're new to physician advisory work, leading a case management team, or running an entire UM department, this casebook gives you the regulatory framework, the operational discipline, and the documentation language that protect your hospital and the patients it serves.

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