At a time when capacity and reimbursement are more important than ever, case managers play a key role in helping operations run smoothly.

One way this happens is through monitoring the entry points of the hospital — what Bonnie Geld, MSW, president and chief executive officer of The Center for Case Management, describes as “those points of access [that] are the various portals for patients to enter into the system.”

These points include the emergency department (ED), post-anesthesia care unit (PACU), direct admission to the units, or transfers from other facilities. This is not to say case managers should now add “security guard” to their extensive list of roles and tasks; rather, they are uniquely positioned to survey the whole picture, including how entry points are used.

Surveying the Landscape

“Surveillance is the opportunity to ensure the patient meets medical necessity criteria for admission to the level of care they are being admitted to,” Geld shares. “This can be inpatient, observation, or outpatient in a bed.”

This surveillance is critically important not only for reasons of capacity and patient flow, but also for its effect on reimbursement. Since medical necessity is a criterion used by payers, ensuring patients meet that condition can help provide the validation needed for reimbursement. For the case manager and the hospital, this situation follows the adage that an ounce of prevention is worth a pound of cure. During a pandemic, preventing admissions without medical necessity can make all the difference — for the hospital and for the patients.

“These portals are the entrance to inpatient beds,” Geld says. “Most hospitals, today, are nearing or at capacity. It is critical to ensure that patients who are being admitted are necessary. This surveillance also gives case management the opportunity to identify and find alternative dispositions to avoid unnecessary hospitalization.”

Unfortunate Effects

“We call RN case management/utilization review the ‘clinical arm of the revenue cycle,’” Geld says. When case managers do not ensure medical necessity for admissions, reimbursement can be negatively affected. Some of those effects include:

  • CMS delegates the hospital to perform medical necessity surveillance. Follow-up audits and claims data might show risk, subjecting the hospital to penalties. The hospital also is responsible for reviewing claims and self-denials when a patient does not meet the appropriate criteria.
  • Commercial payers will deny payment for lack of medical necessity. This is largely based on documentation and the appropriate admission decision. These issues must be monitored by case management to ensure and validate reimbursement. Additionally, some insurers might attempt to underpay if no clear evidence of inpatient need is present.

Another downstream effect from poor flow is the creation of bottlenecks and long waits in the ED, which leads to patients leaving without being seen.

The What and the How

It is well established that case managers should prioritize using appropriate surveillance to guard inpatient beds that might be in high demand. But how is this best carried out?

Case managers “should be assigned to or have some responsibility for surveillance at all entry points. This includes the emergency department, PACU, transfer center, and direct admissions,” Geld explains. “It also means the ICU, as many of these patients must transition to an acute bed where, in fact, there is the highest volume of competition for the bed. Once positioned correctly, they are able to support the teams in guiding physicians to the appropriate level of care and status.”

The next step for case managers is finding and facilitating an alternative disposition for patients who do not meet acute care or observation care criteria.

Geld also suggests hospitals “ensure [the presence of] an RN case manager who performs utilization review functions at all of the entry points. It is important for the physician to feel that the case manager is a good clinical partner and appropriately guides information about status and medical necessity, not recommending it, as it is ultimately the physician’s decision.”

The role of case managers should not be underestimated as they can help make or break the efficiency of the hospital at the entry points. This can affect efficiency in other parts of the facility.

“Case management and social work at the entry points provide a vital and valuable resource for all providers in these areas,” Geld says. “They support appropriate decision-making and status for admissions, help avoid unnecessary admissions through alternative disposition planning, and they manage patients who are high utilizers, helping them return to community providers and support services.”