At Medical City Dallas Hospital, the case management team works closely with the financial team to ensure that patients get the care they need and that the hospital is reimbursed for the stay, says Pat Wilson, RN, BSN, MBA, assistant vice president for case management and transplant services.
Case managers review 100% of admissions to the hospital, she adds. Not all of the patients need case management services, but screening the patients helps identify upfront what patients may be at risk because of their resources, she says.
“Knowing the patient’s benefits not only helps while they are inpatients, but it also helps us plan for post-acute care. When we screen patients upfront, it triggers us to look at ‘what next’ and ‘what if,’” she says.
For instance, a patient who has only Medicare Part A is potentially at high risk because he or she may need post-acute care. “Depending on the circumstances, the case manager may work closely with the social worker, patient, and physician to determine an alternative plan based on available resources,” she says.
When a stay has been denied and patients are still in the hospital, the case managers will request an expedited appeal, which may include a secondary review or a physician-to-physician appeal with the payer.
“If the denial is upheld and there’s no alternative level of care available, we talk to the patient to let them know they may be responsible for the bill. The stay may also be appealed once the final denial is received after discharge,” she adds.
When patients are being admitted, the patient access staff enter all the initial information into a computer program that feeds into case management.
“If we find out a patient’s insurance has changed, we get that information back to patient access,” she says.
Each week, case management representatives meet with patient access staff and review complex cases with reimbursement issues. The meeting is attended by the director and manager of patient access, insurance verifiers, the government program liaison who screens patients for eligibility for Medicaid and the federal health exchange, Wilson, the director of case management, the manager of social work, and key case managers and social workers if their input is needed on a complex case.
The case management team and the patient access team meet separately before the joint meeting and identify high-risk patients and gather information to be discussed at the meeting.
“We brainstorm on what could be done to help the patient and help the hospital get paid,” Wilson says. A case could be something simple like a baby in the neonatal intensive care unit (NICU) who qualifies for government assistance. Someone on the committee is assigned to make sure the family has the information and paperwork they need to apply. Or, it could be someone who has recently lost a job. In that case, someone will talk to him or her about COBRA or the federal health exchange.
If denials occur when the patient is still in the hospital, the case manager handles the appeal. If it’s after discharge, a separate denials team takes care of it.