In this episode, Meliza Weiner, Senior Manager of Revenue Cycle & Clinical Review Nurse here at BESLER provides us with a glimpse into BESLER’s next free Webinar, The Evolving Role of Case Management, presented live on Wednesday, May 7, at 1 PM ET.
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Learn how to listen to The Hospital Finance Podcast® on your mobile device.Highlights of this episode include:
- What to expect with this upcoming webinar
- What case management is
- Regulatory requirements to consider
- Payers and health plans
- Collaborations between case management and other areas of the hospital
Kelly Wisness: Hi, this is Kelly Wisness. Welcome back to the award-winning Hospital Finance Podcast. We’re pleased to welcome back Meliza Weiner, Senior Manager of Revenue Cycle and Clinical Review Nurse here at BESLER. In this episode, Meliza will provide us with a glimpse into BESLER’s next free Webinar, The Evolving Role of Case Management, that we’re presenting live on Wednesday, May 7th, at 1 PM Eastern Time. Welcome back and thank you for joining us, Meliza.
Meliza Weiner: Thank you so much, Kelly, for having me back.
Kelly: All right, well, let’s go ahead and jump in. So could you provide a brief overview of what to expect with this upcoming webinar?
Meliza: Of course. So, the upcoming webinar will focus on the evolving role of case management. It will cover the history of case management, go over some overview and regulatory requirements within case management. We’re going to take a look at different case management roles and various practice settings, as well as the role of case management in healthcare. Now, with that being said, the objectives really are simple. It’s for the attendees and the listeners to gain an understanding of the various roles and the impact of case management in the various settings.
Kelly: Awesome. Sounds like it’s going to be a really valuable webinar for us. So, Meliza, this may seem like a silly question, but what is case management?
Meliza: Oh, that’s funny that you mentioned that. So, case management is not a new notion, right? It has been around, ooh, I would say, more than 90 years, going back to the 1800s. And it’s in the area of psychiatry and social work that focuses on long-term and chronic illnesses. Now, in previous podcasts and webinars I’ve had, I have mentioned that there are several descriptions and, should we say, definitions of case management. And whenever I’m asked this question, I always reference two known case management groups that are leaders in case management, which are the American Case Management Association and the Case Management Society of America. Now, in the interest of time, I’ll just use the definition by the American Case Management Association. They define case management as a collaborative practice model that includes the patients and nurses, social workers, physicians, practitioners, caregivers, and, of course, the community. So, case management really involves communication and facilitation of care along the healthcare continuum, and more so by ensuring effective resource coordination.
Kelly: Wow, that does encompass quite a bit. So, are there any regulatory requirements to consider?
Meliza: Oh, my goodness, there are a lot. So first of all, I do want to mention that regulatory agencies, unfortunately, have had a negative connotation. And what we need to understand that this agencies, regardless if it’s healthcare or not, they exist to make sure that the process, which is basically what we are doing or what we are supposed to be doing or for whatever service or business we are in, is appropriate and within the established guidelines and reasonable standards for that service or business. So as far as case management, there are regulatory agencies such as the Centers for Medicare & Medicaid Services – we know them as CMS – that has a mandate for healthcare organizations that participate in the Medicare and Medicaid conditions of participation, which is basically Title 42. Now, the Social Security Act, which is Section 1861 regulation, and the Quality Improvement Organization. They have standards and guidelines that are requiring organizations and hospitals and health systems have an actual utilization review plan in place. So, with utilization management, it falls under the umbrella of case management, the elements and the foundation of utilization management review are basically reviewing for medical necessity, looking at resource utilization, managing the length of stay, and working on denials and outcomes, all of which affects operations, reimbursement, and revenue.
Kelly: Wow, thank you for sharing all those with us. So does case management have anything to do with payers and health plans?
Meliza: Well, we cannot talk about case management without talking about payers. So, payers and health plans set forth many requirements in contracts, which also affects operations and reimbursement. So having case management doing utilization review, these individuals are really equipped with the knowledge of payer and health plan intricacies. They can bridge the gap between quality care and clinical medical necessity, looking at severity of illness in the intensity of services, coverage, and reimbursement. Also, these management processes are tied to financial policies. It actually makes sure that compliance is followed from a regulatory standpoint, from a quality and risk perspectives. It also provides, of course, for hospitals and health plan operations. Now, with different organizations and healthcare systems, they interpret and implement utilization management review in different ways. But the basic utilization management review could be a plan or an approach that is used for processing claims, for looking at resources and how they’re being used, looking at preventing denials and mitigating risk, and also ensuring that quality is being adhered to.
Kelly: Very cool. Thank you very much for that. And so, what are some of the collaborations between case management and other areas of the hospital?
Meliza: Well, by working with the healthcare team, they can facilitate and coordinate resources and services in a quality manner and in a cost-efficient way. For example, within the quality department, they can be involved in quality assessment, quality improvement activities like evaluating patient care systems that include standards, protocols, and documentation for efficiency. Now, within the area departments of admissions, registration, and scheduling, appropriate communication and documentation of patient status is important, whether it’s inpatient or is it an observation or is it outpatient. Looking at discharge disposition, are they being discharged with home care, or are they going to a long-term care facility or a skilled facility? It helps to make sure that there’s going to be accurate coding. Now, when we’re looking at revenue cycle in the finance department, the impact of case management, their work has tremendous influence on the financial health of an organization. So, it is really important that collaboration exists. Today’s revenue cycle teams have access to lots of data. And with today’s information technology, this can extremely assist with managing length of stay, appropriately allocating resources, preventing denials, and ensuring accurate documentation for coding and appeals. Now, originally, case management departments started with a narrow focus to the point and at times have worked in silos. Now that these departments’ functional activities increasingly influence reimbursement and affect revenue, the impetus of case management playing a role within the finance arena, specifically in revenue cycle, should really be highlighted.
And since we’re talking about revenue cycle anyway, I might as well dive into the utilization review function in case management because it actually helps with managing the cost and the delivery of services. The integration of this function within hospital operations and organizations can increase care efficiency and decrease the loss of revenue. For example, if we’re looking at medical necessity, which is one of the utilization review processes, it involves looking at it prospectively, like looking at the medical necessity for procedures and services before they even get admitted or looking at it concurrently, which is basically an ongoing review of the medical necessity for procedures and services while they’re in the hospital. And you can also look at it afterwards, which is what we call a retrospective review. So, these processes alone can significantly decrease the length of stay, help manage the appropriate use of resources and services, as well as preventing denials and protecting your revenue. Now, there are some of the other various activities within case management that is important to hospital or operations like pre-admission and admission certification, looking at discharge planning, and even making referrals for resources that are needed like nursing services after they get discharged, social work services, pharmacy, respiratory therapists, physical and occupational therapy services.
Kelly: Wow, there’s a lot of responsibility there, and I love all that collaboration that the case managers have. So do case managers only work in hospitals?
Meliza: Ooh, not at all. Not at all. Case managers are all over. You will see them, not in the hospitals like we talked about, in acute care, where they do utilization review, discharge planning, and care coordination. You will also see them in accountable care organizations. They’re also working with behavioral and mental health. You’ll see them with home care, hospice, palliative care. In fact, they function in a dual role, working as a case manager and direct caregiver.
Kelly: Very interesting.
Meliza: You’ll see them in long-term care facilities. You’ll see them in disability services, government, military. You’ll even see them in VA organizations, community-based organizations, even in independent practices with doctors’ offices, outpatient clinics. The one thing that is rarely mentioned, but they’re always working with workers’ compensation. Their focus is helping the employees and the employers to get the employee back to work, and also in insurance companies and managed care organizations. These are just some, believe it or not, a few, of what I’ve mentioned. But the Case Management Society of America created an extensive list of practice settings, most of which will be covered in the webinar.
Kelly: That’s awesome. I love all of that. So, thank you so much for joining us, Meliza, and for sharing this really great sneak peek into your upcoming webinar, The Evolving Role of Case Management, that you’re presenting live on Wednesday, May 7, at 1 PM Eastern Time. And as a bonus, you can earn CPE. Thanks again, Meliza.
Meliza: Thank you, Kelly.
Kelly: And thank you all for joining us for this episode of The Hospital Finance Podcast. Until next time…
[music] This concludes today’s episode of The Hospital Finance Podcast. For show notes and additional resources to help you protect and enhance revenue at your hospital, visit besler.com/podcasts. The Hospital Finance Podcast is a production of BESLER | SMART ABOUT REVENUE, TENACIOUS ABOUT RESULTS.
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