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In today’s world, it is imperative for the case management director to make sure the case management staff receives continuous training and education around payer rules and regulations, and the financial implications of what they do, says Mindy Owen, RN, CRRN, CCM, principal owner of Phoenix Healthcare Associates in Coral Springs, FL, and senior consultant for the Center for Case Management.
“Case managers’ daily responsibilities include managing within the Medicare Conditions of Participation, variance in Medicaid plans, third-party payer contracting, and a large number of patients who are self-pay, foreign nationals, or indigent. That’s why the case management director needs to have a fully formulated training plan to make sure the staff knows the current payer requirements,” Owen says.
Owen points out that, on average, hospitals receive close to 50% of their revenue from Medicare, and a large portion of revenue comes from Medicaid.
“Case managers need to be aware of state and federal regulations and work with the revenue cycle team to ensure timely revenue collection,” she says.
Commercial insurers’ rules and regulations present another challenge, adds Brian Pisarsky, RN, MHA, ACM, associate director at Berkeley Research Group, headquartered in Emeryville, CA. He recommends developing common language for insurance contracts so the rules around certification, appeals, and denials will be consistent.
For insurers that don’t agree to common language, case managers should have a contract grid that includes pertinent payer information such as how often the reviews are required, what criteria to use, phone numbers for the case managers at the insurance company, what post-acute providers are in the insurer’s network, and other information, suggests Teresa McNulty, RN, BA, ACM, IQCI, director at Huron Consulting Group, a Chicago-based healthcare consulting firm.
Case managers also need to know if patients are part of a bundled payment arrangement or a value-based purchasing agreement, Pisarsky says.
“This is becoming a bigger concern and it’s not always easy to determine,” he adds. For instance, if a patient falls within a bundled payment, the case managers need to know that this may affect discharge planning options.
Case managers need to understand what is and isn’t covered so they can inform families they may receive a bill for services that are excluded. “Case managers don’t need to know the exact dollars and cents the patient may owe; however, they need to tell them that certain services may not be reimbursed so the family won’t be blindsided when they get the bill,” Owen says.
A big challenge for case managers is knowing the language in each contract concerning the appeals process, including whether the hospital can appeal denials concurrently, says Beverly Cunningham, RN, MS, consultant and partner at Oklahoma-based Case Management Concepts.
“Case managers don’t need to know contract details such as how much the hospital is paid or what constitutes an outlier. What they do need to know is when and how to appeal and the time requirement for clinical information,” Cunningham adds. For instance, some insurers require concurrent appeals within 24 hours of being issued, which means case managers have to get the physician involved quickly.
Until hospital case managers know what is in the contract, case managers at the insurance company can tell them anything, Cunningham says.
One of the biggest issues is payers’ lack of timely responses to information provided by case managers, McNulty says.
For instance, there may be a significant delay in authorization after the case manager submits a clinical review or the payer may issue a denial of a concurrent stay after the patient has been discharged from the hospital, which limits the ability of the case management team to concurrently appeal the case and facilitate timely payment rather than a prolonged appeal process after billing.
“There is a lot of variability in payer requirements and sometimes they ask for things that are unreasonable,” she says. For instance, a payer case manager may arbitrarily issue denials if the reviews aren’t received by 3 p.m., but the requirement is not in the contract.
“Case managers and utilization review nurses should be well versed in what is expected of them and share the information with the contracting team when the payer is being unrealistic,” she says.
Managing Editor Jill Drachenberg, Associate Managing Editor Dana Spector, and Editor Mary Booth Thomas, report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study. Nurse Planner Toni Cesta, PhD, RN, FAAN, Consulting Editor of Hospital Case Management, is a consultant with Case Management Concepts LLC.