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Case management directors can train staff to log their hours, maintain accurate documentation, and follow all payer rules and requirements to maintain compliance with laws and regulations.
Directors also might keep in mind that certain actions or issues can be red flags to auditors and regulators.
“If case managers understand what the red flags are, they’re more likely to be cognizant,” says Chris Ambrose, MBA, CHC, CHPC, healthcare compliance officer at Service Access & Management in Reading, PA.
The following are some of the more common red flags:
• Billing for services that are not reimbursable. Case managers should know exactly which services are included in what payers will cover and document these accurately.
• Overlapping services. A case manager might bill for one patient from 3 p.m. to 3:30 p.m. and bill for a second patient from 3:25 p.m. to 4 p.m. That means there were five minutes of overlapping billing open to scrutiny, Ambrose says.
• Billing for travel time. If a patient’s service does not reimburse for travel, case managers should be certain to document appropriate transition time between appointments. For instance, if the case manager documents that one patient’s service ends at 4:20 p.m. and then documents that a second patient’s service begins at 4:20 p.m., the payer will know that it is impossible for the case manager to have seen the two people in that span of time when they live 10 minutes apart, he explains.
• Ensuring clients sign all necessary paperwork. “Make sure clients have signed all information and appropriate documentation that you billed for,” he says.
• Report problems. “Case managers also need to know they are expected to report clients’ concerns and any potential compliance concerns,” Ambrose says.
“Nonreporting has the worst outcome for the organization,” he adds. “Putting your head in the sand, pretending you didn’t see an issue, will have the worst outcome.”
Financial Disclosure: Author Melinda Young, Editor Jill Drachenberg, Editor Jesse Saffron, Editorial Group Manager Terrey L. Hatcher, and Nurse Planner Margaret Leonard report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.