Thinking Like a Payer
By Jeni Miller
Part of what makes so many case managers successful is their ability to understand countless roles within healthcare and move between them smoothly. Whether managing discharges, providing social work support, or completing utilization review, the case management experience often is varied.
However, many struggle in the quest to work more seamlessly with payers. Unless a case manager has spent some time in that role, it can be difficult to understand that side of the experience and provide proactive support.
Donna DeFilippis, BSN, RN, ACM-RN, lead nurse case manager, utilization/case management for Nemours Children’s Hospital in Delaware, started out working in case management and utilization management (UM) in 1997, and later went on to work with Delaware Medicaid for more than 13 years. Her experience in working on the payer side helped her hone the ability to “think like a payer” even as she has returned to the hospital case management side.
“It was a learning curve at first because the way we perceived the insurance company was like going to the dark side,” DeFilippis recalls. “But in working as a case manager, it allowed me to build skills because I learned the do’s and don’t’s and ins and outs of payers, all toward helping manage patients in the hospital and providing the best possible care we can for the best possible outcomes.”
Even with extra experience, keeping track of all the nuances and particulars for each payer can be difficult. “As a case manager, you’re looking out for the organization in regards to cost, and maintaining a balance of not getting denied days,” DeFilippis explains. “What helped me all these years is learning an array of information because every payer is different. Whether commercial plans or Medicare, each payer has their own set of guidelines and rules. Some payers have payments based off of a DRG [diagnosis-related group], and others are a fixed rate, so trying to keep track of each payer and contract that an organization has can be difficult.”
When DeFilippis worked on the payer side, relationships and collaboration with case managers mattered significantly. “If I had a strong relationship and collaboration with the facility, it was great knowing you’re doing the most appropriate thing for the patient,” she says. “You still have to work within the criteria sets and guidelines. If the patient is not meeting medical necessity, then we have to send to the medical director, but at least having a relationship with a case manager who gave updates, shared the goals of treatment, anticipated discharge needs — all of that helped and could reduce the potential for denials.”
Knowing this has informed how DeFilippis functions in case management. If medical necessity is in question, DeFilippis can inform the physician they are at risk of a denial. Asking the physician if there is anything that can be handled differently or to talk to the payer to give a more in-depth perspective can make all the difference.
“Being in communication with the payer in advance is critical,” DeFilippis notes. “If I know something is coming up about the patient, I can provide additional information to that payer to help mitigate a potential denial or provide appropriate documentation that specifies medical necessity. Sometimes, it’s as simple as using the word ‘monitoring’ instead of ‘observing’ the patient, as that can affect how [the payer] sees it as inpatient vs. outpatient.”
It is not the payer’s goal to issue denials, DeFilippis says. They are issued for various reasons. Often, it is not related to the case manager’s lack of familiarity with the payer side but can simply come from a lack of relationship or genuine inexperience of the payer’s UM nurses.
“Not all UM nurses on the payer side are experienced — their skill sets vary,” DeFilippis explains. “It can make all the difference when you submit clinicals to an inexperienced nurse. For example, if you have a baby on prostaglandins, some UM nurses might not know about that, and a denial might happen because payers are not as well equipped at knowing the criteria. They might send to the medical director for a denial when in reality it should never be sent. In those situations, I find myself literally telling them, ‘You need to call this person,’ or ‘Let me speak to the medical director.’”
On the case management side, it is possible to gather more experience in working not only with payers, but in other areas that can help round out the case management role. At Nemours, leadership found their people were comfortable with their areas of expertise but faced challenges while covering for colleagues.
“We switched over and changed their assignments every four months and it’s been a great success,” says Miken Sarkissian, BSN, RN, utilization management supervisor. “We’re seeing more continuity and they’re getting to know payers and nurse reviewers on the payer side. As they’ve formed those relationships, they are getting denials overturned with conversation or consideration rather than the appeal route on occasion.”
About Those Denials
According to DeFilippis, when Nemours implemented their case management program in the cardiac center in 2017, they reduced the number of denied days from 200 to 43, then improved their rate of overturned denials from 68% to 95%. This represented a cost savings of more than $1.5 million. They currently report a low denial rate of approximately 0.3%, with a benchmark at 1%, primarily because they appeal these denials aggressively, DeFilippis notes.
The success is due in part to case managers studying the clinicals, securing added documentation, and avoiding potential denials. DeFilippis also attributes it to the strong relationships between the UM nurses and case management nurses at Nemours, who all have a good rapport with payers and their nurses.
“They communicate quickly when there is word of a denial, and then they can go to the physician to notify them as well,” DeFilippis says. “Often, these are peer to peer for physicians.”
In the past, it was more difficult. “Now, the physicians know who the case managers are, and they don’t refuse to do peer to peers like in the past,” Sarkissian adds.
Besides preventing denials, thinking like a payer also brings a few other added bonuses.
“One of the benefits of working with the payer closely is that it helps prevent delays in discharge when it comes to obtaining prior authorizations, especially for durable medical equipment, hospital transfers, home care, prescriptions, and more,” DeFilippis explains. “What it comes down to is communication — being able to know where to find information on the payer and knowing who to call. Then getting in touch with them on a daily basis and contacting the UM nurse and communicating with them early about discharge planning. We want to make sure that we get the services that the patient needs.”
DeFilippis recalls orienting new case managers who had no case management experience or insurance information from the payer side. “It was important for me to mentor them if, for example, we were transferring a patient to another facility for a surgical procedure,” she says. “Each payer is different, but you can mentor the new case manager and guide them to see you need to make sure they have medical necessity and notify the payer in advance as soon as you know. If you’re looking at transferring the patient to an out-of-state hospital, explain to the payer that you’re going to need XYZ and communicate with them to expedite authorization. Once you know how to navigate the barriers, and you begin to build rapport with the payer, you become more comfortable with that flow.”
It is helpful to educate the case management team more thoroughly about payer perspective, not only to help reduce denials or expedite discharge, but because it is a good thing to want the hospital to receive the appropriate payment for providing care for their patients.
A Change in Perspective
A final reminder as case managers consider the payer’s perspective in their everyday interactions is the centrality of the patient throughout the whole process.
“The payer has certain specifics in those contracts, but we need to keep in mind at all times how can we get the patient what they need from this payer,” DeFilippis says. “Sometimes, we have to reword things to get a different response. Other times, we might not always have to give full details because then it can actually be too much information. We should just give what they ask for.”
DeFilippis recalls when she first started as a case manager, there were “misconceptions about insurance companies, and when we would get pushback from the payers it would leave a bad taste.”
“Remember that they don’t purposely try to be difficult as they have workflows they have to follow, and our common goal is the patient and getting them the services that they need to have best possible outcomes when they’re discharged from hospital,” DeFilippis says. “The payers aren’t trying to get denials. They are looking at cost savings and providing for their participants, just like hospitals are working to provide the best possible care for patients.”
Part of what makes so many case managers successful is their ability to understand countless roles within healthcare and move between them smoothly. Whether managing discharges, providing social work support, or completing utilization review, the case management experience often is varied. However, many struggle in the quest to work more seamlessly with payers.
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