On-site case manager creates win-win situation

An example of a collaboration that works

At St. Vincent Hospital in New York City, the case management department has welcomed a payer case manager who works on-site five days a week. "He has almost become part of my staff. It really fosters a positive relationship and is to our advantage," says Toni Cesta, PhD, RN, FAAN, director of case management.

In addition, the hospital has a physician advisor who works out of the case management department and intervenes with insurers when he feels that hospital is right. "His relationship with insurance company medical directors has served us well," says Cesta. "He overturns 79% of the denials he gets involved with."

The secret to the physician’s success in overturning denials may be that he won’t get involved unless he feels that patient is truly sick and needs to be in the hospital. "He has increased his credibility because they know when he calls that his comments are legitimate," Cesta says.

The on-site insurance case manager works directly with the staff and has office space and a telephone at the hospital. "Some places find it scary to have an insurer’s case manager physically in the hospital looking at patients and charts. In reality, I’ve found it to be quite the opposite," Cesta says. "They are on-site, so they get to see how sick patients are. We have fewer denials by having people on-site for the insurance company."