Educate yourself on compliance requirements

Know the steps to follow to report problems

As Mindy Owen, RN, CRN, CCM, travels around the country for the Commission for Case Manager Certification (CCMC), she’s always surprised to find how few case managers are familiar with the standards of practice under which they operate.

"Case managers should become very familiar with and follow the standards of practice for their profession. They are the foundation for the practice of case management," says Owen, past chair of the ethics committee and a member of the executive board of the CCMC and principal of Phoenix Health Care Associations in Coral Springs, FL.

Case managers who work for an organization that has been accredited by an accrediting body or that is looking at accreditation should be familiar with the standards from that accrediting body as well, she explains.

For example, the Joint Commission on Accreditation of Health Care Organizations, the National Committee on Quality Assurance, and the URAC all have compliance standards that health care providers must meet for certification.

All case managers, whether they have been certified by the CCMC, are held to the code of conduct that has been established by that organization, Owen points out. "In a court case, if an attorney asks case managers about the code of conduct, the fact that they have not been certified does not exempt them from culpability."

Case managers also should be familiar with compliance guidelines for Medicare, Medicaid, and other federal and state programs as well as those from commercial health insurance companies, says Elizabeth Hogue, a Burtonsville, MD, attorney in private practice specializing in health care. Some sources for education include professional organizations, professional journals, and publications, she adds.

Be very clear about and able to articulate the philosophy and mission of the organization with which you are employed, and make sure your case management efforts are aligned with the mission of your organization, Own suggests.

"Ethical, legal, and noncompliance issues often come from nonalignment. If employees and their organizations have the same philosophy and the same understanding of the ethical process, they’re not as likely to get into trouble. But when the organization is going in one direction and the case manager in another, that can lead to a breakdown in communications and possible noncompliance consequences," she says.