Hospitals that pile task after task on case managers and assign them large caseloads are unlikely to effectively manage denials, says Beverly Cunningham, RN, MS, ACM, consultant and partner at Oklahoma-based Case Management Concepts.
“If a hospital doesn’t have [an] appropriate patient-to-case-manager ratio, it will never have effective denial management,” she says.There’s no magic number for the caseload a case manager can handle, she adds.
But the type of payer and their requirements can be a guide in determining the caseloads, suggests Tina Davis, RN, MS, CMAC, senior consultant for the Center for Case Management. Compile a spreadsheet of all payers and include preauthorization and continuing stay requirements along with whether they pay on a per diem or diagnosis-related group (DRG) basis.
Case managers at a hospital that has a significant number of per diem payers that want a review on a daily basis should have a smaller caseload than a hospital with mostly DRG payers who don’t require frequent reviews, she adds.
Cunningham recommends having one case manager responsible for care coordination, clinical discharge planning, and utilization management for one group of patients. But, often, it doesn’t happen because hospitals cannot attract enough case management staff to provide the appropriate ratio, she says.
“If there isn’t a workable ratio of patients, there’s no way the case manager can get everything done. They can perform only reactive case management,” she says.
Separating the utilization management function from the case management function also can put a crimp in denials management efforts, she adds.
“When case managers and utilization management staff operate separately, it creates silos. If there are separate staff for each function, the case management leaders and the utilization management leaders must be aligned and the case managers, social workers, and utilization management staff must collaborate closely,” she says.
Cunningham compares separating utilization management and case management functions to separate conductors leading the orchestra, with the result that the drums start beating before the violins begin playing.
When case management and utilization management are separate functions, it often creates delays, Cunningham points out. For instance, the utilization manager determines that a patient no longer meets medical necessity and sends a message to the case manager. But by the time the message is received, the physician already has made rounds, and the case manager must scramble to locate him or her. Then, the case manager must ask the physician to add to the documentation to support the medical reason the patient is in the hospital. By then, so much time has passed that the payer may deny the entire stay or pay only for observation — or, for a Medicare patient, he or she may already have been discharged from the hospital.
“Sometimes, even if you do the right thing it may be denied because it’s late,” she says.
In today’s healthcare environment, the position of appeals coordinator is critical, Cunningham says. “How many appeals coordinators are needed depends on the size of the hospital, but there has to be someone on the staff who understands the denials process, how denials occur, why they occur, and how and why they occur from each individual payer,” she says. He or she also must be familiar with the rules and regulations associated with self-denial, she adds.
The appeals coordinator should understand the nuances of traditional Medicare and Medicare Advantage plans, Medicaid and Medicaid HMOs, and be familiar with all of the commercial payers with which the hospital contracts, she says.