Over the past several issues of Hospital Case Management, we have reviewed the top seven issues you may be facing in your case management department. This month, we are continuing with the final three issues related to opportunities for improvement in how you structure and organize your case management department, as well as how things are operationalized by the staff.

Case Management Department Mistake Number Eight: “Lack of Access Point Case Management”

Number eight on our list has to do with Access Point case management, which includes applying the roles and functions of case management in the most commonly used routes of entry to the hospital.

There are many reasons why you should have Access Point case management in your hospital. Below are the top 10 reasons:

1. Assign an appropriate level of care and/or appropriate placement from the point of entry.

2. Assure compliance with medical necessity.

3. Reduce Recovery Audit Contractor (RAC) activity.

4. Reduce readmissions.

5. Improve inpatient throughput.

6. Reduce the need to use Condition Code, provider liable billing, or self-denials for two-midnight rule.

7. Initiate timely utilization management and discharge planning.

8. Reduce admission and inpatient-only denials.

9. Manage observation service.

10. Increase patient satisfaction at access-covered entry points.

For most hospitals, at least 50% of admissions enter via the emergency department. For some, this percentage can be as high as 80%. However, consideration must be given for all hospital routes of entry. Routes of entry can include any, or all, of the following:

• ED

• Direct admission from physician office

• Outpatient sites in facility

• Cath Lab

• GI lab

• Clinics

• Therapies

• Special procedures

• Ambulatory surgery center

• Same day surgery

• Scheduled admission

• Transfer in from another facility

• Hospital

• Free-standing ED or clinic

Because of the wide array of ways in which patients can enter the hospital system, the following positions are recommended for any contemporary case management department:

• Admission Case Manager

• Emergency Department Case Manager

• Peri-Operative Case Manager

Depending on the size of your hospital, the roles listed above might become one, two, or three different positions. If your hospital is on the smaller side, the three could be combined into one as long as the roles are covered adequately.

The Admitting Department Case Manager’s roles and functions should include the following:

• Screening of potential admissions (planned, urgent, direct) and transfers.

• Use clinical indicators.

• Compare patient’s severity of illness and intensity of service against established criteria and/or regulation, such as the two-midnight rule.

• When the patient’s needs do not meet admission criteria and/or the two-midnight rule documentation is not met, a physician is contacted.

• Care alternatives are discussed.

• Review prior to day of admission to ensure that payer authorization has been obtained.

This position should be located in the admitting department and should work closely with the admitting staff while still reporting to the case management department.

If your hospital has an emergency department, then the ED case manager position should not be considered optional, but rather a necessary component of the department’s infrastructure.

The Emergency Department Case Manager’s roles and functions should include the following:

1. Gatekeeper: In the role of gatekeeper, the ED case manager screens all patients for appropriateness of admission. The ED CM also ensures that the appropriate documentation to support the admission is in the medical record. When the patient does not meet medical necessity, then the ED CM can offer alternatives to admission to the hospital. In the role of gatekeeper, the ED CM should also initiate contact with the admitting physician and the primary care physician, if they are different.

2. Facilitator of care: In the role of facilitator, the ED CM can expedite tests, treatments, and procedures on any patients presenting in the ED as time allows. This would include the treat and release, admitted, and observation patients.

3. Intake/utilization management process for inpatients: This is an important role for the ED CM, particularly for those patients being held in the ED, waiting for an inpatient bed. The ED CM can collect information from many sources as listed below:

• Assess current living situation

• Obtain info regarding informal and formal supports

• Review lab and ancillary test results

• Start discharge planning on admitted patients

• Review history

• Speak with ambulance staff

• Meet with family/friends

• Review patient’s insurance benefits

• Introduce idea of home care or other alternative services

• Interface with inpatient case managers

• Check that patient has a primary care physician with whom they are comfortable

• Perform a readmission root cause analysis on any patients being readmitted within 30 days.

Based on the data collected, the CM can provide an initial assessment that can be passed to the inpatient case manager and can also provide any clinical reviews that are required by a third-party payer.

4. Manage high-utilization patients:

• Identify high-utilization patients

• In ED at least once every three months

• Patients discharged as inpatient in past 30 days

• Create care plan with ED staff and primary care physician (if patient has one)

• Refer to appropriate level of care: detox/rehab programs, SNF, group home

• Assist with medications, as appropriate

• No meals/showers/clothes/money

• Consistent approach.

The peri-operative case manager manages patients from the pre-admissions process through to the post-anesthesia recovery unit (PACU).

The peri-operative case manager roles and functions should include the following:

• Meet and “intake” triaged patient groups during pre-admission process

• Identify any pre-admission issues that might affect the in-hospital stay and/or discharge plan

• Explore discharge planning options with patient/family to set expectation for discharge disposition

• Review patient’s payer benefits plan

• Discuss with attending physician when post-discharge needs cannot be clearly identified or do not meet patient’s benefit plan

• Refer to inpatient social worker/case manager as appropriate

• Assure inpatient-only procedures have appropriate order

• Coordinate PACU patients

• Discharge planning needs for day surgery patients

• Appropriate order for patients needing observation service or extended recovery

• Provide education to physicians

• Role and functions

• IP-only procedures

• Two-midnight rule

• Levels of care and documentation

• Document all patient interaction, planning and coordination.

While your hospital may have other high-volume routes of entry, the three positions listed above should, in general, cover the majority of patients entering your system.

Case Management Department Mistake Number Nine: “No Control over External Auditors and Physician Advisors”

The best way to deal with auditors is to do what you can to keep them from having to audit your department.

Strategies to keep auditors at bay include the following:

• Put patient in appropriate status

• Get admission order correct

• Follow the two-midnight rule guidelines

• First order: Expectation of patient to spend greater than one midnight or less than one midnight in the hospital

• IP order: Proceed with medical necessity evaluation, reviewing physician documentation for support of hospital services that require IP

• Observation order

• Discharge plan discussed

• All orders authenticated, dated, and timed before patient discharged (by physician).

It is important that you hardwire these processes so that they do not get overlooked or skipped. It is also important to self-audit on a regular basis to ensure that the processes are still in place. Monthly audits with a standard template are the best way to go.

The role of the physician advisor (PA), whether internal or external, needs to be managed as well. There are some standard elements that the PA can perform that will help the case management department operate more smoothly. The PA needs to be trained and educated in utilization management in order for the position to be utilized to its maximum. Once accomplished, the PA can become a valued resource for the case managers regarding specific or challenging utilization management situations. Having a PA in the department can help to increase the case managers’ credibility with physician partners. The PA serves as a liaison with the medical staff, case management staff, hospital administration, and third-party payers. You should consider your PA as a collaborative and influential member of the medical staff and as such, they should participate in interdisciplinary team conferences and other committees as appropriate. It is sometimes helpful to have the PA chair the utilization management committee as well.

Whether you choose to have an internal or external physician advisor will depend on the needs and resources of your hospital. An external PA may be needed when you don’t have a best-practice physician advisor on staff. Or you may have a physician advisor on staff who is a novice in the position and so you may need the support of an external PA. Finally, if you do not have coverage seven days a week, you might choose to supplement your internal PA with external resources to cover days off.

No matter what your structure is, you need to maintain control over the processes. Be sure that you have data that you collect, analyze, and report on. Reporting should be on a regular and scheduled basis. Audit regularly as well and you will maintain control of these important aspects of the department.

Case Management Department Mistake Number 10: “Lack of Compliance with the Conditions of Participation”

The Conditions of Participation, as outlined by the Centers for Medicare & Medicaid Services (CMS), have two sections that relate to the functions of case management. These include the conditions of participation for utilization review and for discharge planning. The hospital must comply with all the conditions in order to participate in the federal healthcare programs. Each department of case management needs to ensure compliance to these two conditions. The only way to know if you are compliant is to self-audit and be sure that all expected elements are present.

Listed below are the main areas for audit and compliance of the conditions of participation for utilization management:

• All hospitals must have a utilization review plan. The plan must provide for review of services furnished by your institution and members of medical staff to patients entitled to benefits under Medicare and Medicaid programs.

• All hospitals must have a utilization review committee.

• Hospitals must ensure that all utilization review activities, including review of medical necessity of hospital admissions and continued stays, are fulfilled as described in 42 CFR 482.30.

The conditions of participation for discharge planning are more complex than those for utilization review. They require the following:

• Discharge planning processes that apply to all patients.

• Policies and procedures in writing.

• Identification at an early point in the hospitalization of all patients likely to suffer adverse health consequences upon discharge if there is no adequate discharge planning.

• Discharge planning evaluation to patients identified as above, and to other patients upon patient’s request, the request of a person acting on patient’s behalf, or request of the physician.

• Supervision of plan development and plan evaluation by registered nurse, social worker, or other appropriately qualified personnel.

• Discharge planning evaluation.

• Evaluation of the likelihood of a patient needing post-hospital services and availability of the services.

• Evaluation must include evaluation of the likelihood of patient’s capacity for self-care or possibility of patient being cared for in the environment from which he or she entered the hospital.

• Evaluation must be completed timely so appropriate arrangements for post-hospital care are made before discharge, to avoid unnecessary delays in discharge.

• Include discharge planning evaluation in medical record for use in establishing appropriate discharge plan and must discuss results of evaluation with patient or individual acting on his or her behalf.

• Reassess patient’s discharge plan if there are factors that may affect continuing care needs or appropriateness of the discharge plan; reassessment must include a review of discharge plans to ensure that they are responsive to discharge needs.

• As needed, the patient and family members or interested persons must be counseled to prepare them for post-hospital care.

• Transfer or refer patients, along with necessary medical information, to appropriate facilities, agencies, or outpatient services, as needed, for follow-up or ancillary care.

Conditions of Participation and Patient Choice

Many hospitals still struggle with the best way to give patients choice and what to give choice for. According to CMS you should:

• Include in the discharge plan a list of home health agencies (HHAs) or skilled nursing facilities (SNFs) available to the patient that are participating in the Medicare program and the serve geographic area (as defined by the home health agency) in which patient resides, or in case of a SNF, in geographic area requested by the patient. HHAs must request to be listed by hospital.

• List must only be presented to patients for whom home healthcare or post-hospital extended care services are indicated and appropriate as determined by discharge planning evaluation.

• For patients enrolled in managed care organizations, the hospital must indicate availability of home health and post-hospital extended care services through individuals and entities that have contracts with managed care organizations.

• Must document in patient’s medical record that the list was presented to the patient or individual acting on patient’s behalf.

• Must inform patient or patient’s family of freedom to choose among participating Medicare providers of post-hospital care services and must, when possible, respect patient and family preferences when expressed; the hospital must not specify or otherwise limit qualified providers that are available to the patient.

• Discharge plan must identify any HHA or SNF to which the patient is referred in which the hospital has disclosable financial interest.

While you may want to discuss choice with your patients for other services such as acute rehabilitation or durable medical equipment, you are not required to give them a written list of hospitals or vendors. Patients may have particular preferences and you should always give them the option of choice when appropriate. However, for compliance with the conditions of participation, lists are only necessary for home health and skilled nursing facilities.

CMS recommends that the discharge planning process be performed at least 48 hours before discharge and requires surveyors to make sure that the discharge wasn’t delayed because discharge planners didn’t do a timely evaluation. If hospitals don’t evaluate all patients for post-discharge needs, they should have a system to ensure there is a way for discharge planning staff to learn if a patient’s condition changes to the point that he or she will need post-discharge services.

CMS wants discharge planners to assess that the patient’s discharge needs can be met in their previous living environment. You should also be sure to document whether patients and/or family members have the ability to take care of the patient’s needs after discharge. If not, discharge planners should make sure that there are community-based services that can provide care and needed services in place when the patient is discharged.

Auditing for Compliance

At a minimum, be sure to audit the following:

• All one- and two-day stays for traditional Medicare patients that have not been reviewed by a case manager.

• Utilization management documentation and accuracy.

• Patient choice documentation.


We have now completed our review of the top 10 mistakes you may be making in your case management department. I’ve included tips and strategies for correcting these mistakes if you are facing them in your organization. If you follow these suggestions, you will help to keep your case management practice and your department on track and moving forward!

For more information on the CMS Conditions of Participation, go to: