Case Management

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Case Management: The Bridge Between Clinical Practice and Financial Performance

As a midstream component of the revenue cycle, a Case Management department stands at the intersection between clinical practice and billing results and serves as a critical bridge between the two disciplines.

While Case Management departments will be primarily comprised of Nurse Case Managers and Licensed Social Workers, case management processes at mature organizations will involve Patient Access personnel, physicians, nurses, clinical providers, coders, and clerical staff in the clinical environment or in support areas. Each must have timely access to clinical and financial information regarding patient care and the specific services and supplies used in the delivery of patient care.

Implement our Care Management-RC™ methodology to optimize the following critical case management components:

Case Management Key Components

Component 1: Utilization Management

Utilization Management: Validating the “medical appropriateness” or “medical necessity” of care. This component answers the question: “Is the patient receiving clinically necessary services in the most cost-effective setting possible, within payment constraints”?

Component 2: Concurrent Review

• Concurrent Review: Ensuring the documentation of services is complete and accurate. This component answers the question: “Does the clinical record accurately reflect patient status, documentations of interventions, comorbidities and/or interventions and documentation of the treatment plan to reflect the severity of illness as well as the intensity of services”?

Component 3: Care Facilitation

Care Facilitation: Expediting care, following up on diagnostic studies and tracking the patient’s progress toward discharge. This component answers the question: “What needs to be expedited to meet treatment goals and prepare the patient for the next level of care”?

Component 4: Discharge Planning

Discharge Planning: Focusing on transitions of care, which includes a complete transfer to the next care setting. This component answers the question: “Where can the patient’s post-discharge needs be met most effectively and at the lowest cost”?

Challenge

Solution

Challenge

The field of access management has changed dramatically over the years. Patient Access Services personnel must navigate in an increasingly complex technical, financial and regulatory environment.

Misunderstanding of Case Management’s Financial Role

Because hospitals often misunderstand the case management role in communication with payers, much time and effort is misallocation to other revenue cycle stakeholders like patient access or patient accounting. This misallocation creates costly duplication of efforts and claim denials.