Case Managers are Link Between Clinical, Financial Sides.

Abstract

As reimbursement tightens and payers issue ever-changing rules, it’s essential for hospital case managers to be involved in the revenue cycle by managing patients on admission, or even before they arrive, and following them through their hospital stay, ensuring that payer requirements are met so the hospital can get appropriate reimbursement. • Case management directors should meet regularly with representatives of the financial side of the hospital to discuss reimbursement issues and review the portion of insurance contracts that relate to the responsibilities of case managers. • Case managers should cover all access points of the hospital to prevent denials before they occur by ensuring patients meet inpatient criteria and are place in the right status. • Case managers should review every patient every day to make sure the days of hospitalization are authorized, that appeals are conducted concurrently, and that the discharge plan continues to meet the patient’s needs. • Hospitals need to provide continuous education to make sure that case managers understand the changing payer rules and regulations to know what each payer requires, and how and when to appeal.