February 19, 2019
Case managers play a critical role in revenue cycle management; but in most health systems, these professionals are isolated from the financial side of the business, lacking key details and relationships that could have a significant impact on the revenue cycle.
Case managers’ responsibilities range form utilization management to discharge planning to care coordination — all areas that have direct impacts on the revenue cycle. They play a critical role as a liaison between insurance payers and hospitals, making sure facilities are doing all they can to earn proper reimbursements, and advocating on behalf of patients.
Case managers play an integral role in all phases of inpatient acute care.
1 – Pre-Admission
As with the revenue cycle, case management begins before the patient enters the hospital doors. Case managers need to be aware of the patient’s outpatient care experience and their admissions process.
How patients are classified at this stage (inpatient versus observation, for example) will impact the entire billing process from admission through discharge and can cause or prevent reimbursement issues.
2 – Admission
Case managers review new admits to ensure they meet requirements for medical necessity and are classified appropriately following utilization criteria, helping to prevent denials before they occur. Of most importance at this stage are activities that can prevent extended length of stay, avoidable inpatient days, and subsequent denials. Also critical to reimbursement and avoiding future penalties is beginning the discharge planning at this early stage to prevent costly readmissions.
If disputes over medical necessity arise, case managers can serve as a mediator between physicians and the payer’s medical director.
3 – Concurrent
During the inpatient stay, case managers are busy acting as an intermediary between physicians, clinical care teams, patients, payers, and post-discharge providers such as home healthcare and skilled nursing. Their role is essential to accurate coding and timely billing.
Effective case managers also continually review and update clinical progress and compare against treatment and discharge plans to be sure the level of care is on pace to meet the patient’s goals. These utilization reviews are critical for insurance payers as they review for medical necessity and are pivotal in reducing length of stay to hedge the probably of insurance denials and tighten the revenue cycle.
Communication and shared understanding between all clinical and administrative departments that have a hand in the revenue cycle are critical to minimizing the days a case spends in accounts receivable, thereby reducing the risk of denials.
4 – Discharge
In value-based care models, quality outcomes have a direct financial impact. Early discharge planning and strict utilization management reviews by diligent case managers can result in full authorization of inpatient days and reduce potential delays in payment.
Ineffective or uninformed discharge plans can produce longer than necessary lengths-of-stay, prolonged appeals, high readmission rates, and a negative impact on the revenue cycle.
5 – Post-Discharge
After the patient leaves the acute setting, there is still ample work for case managers to do. Chief among these post-discharge responsibilities is following up with at-risk populations to mitigate their risk of readmission. Case managers ensure all parties are following the patient’s discharge plans and that patients have access to all the care and equipment they need to continue healing.
No matter how diligent a case manager is, claims denials are inevitable. Successful case managers will actively follow up with and appeal denials to decrease write-offs and time spent in accounts receivable.
Financial leaders will be well served to work closely with case managers for joint fiscal success. Representatives from both departments should meet regularly to review insurance contracts, discuss reimbursement challenges, identify trends, and plan for preventing future denials.
Shared data between the finance department and case managers can highlight trends and improvement opportunities in critical areas such as cost per case, length of stay, denials, denial rates, overturned denials, and potentially avoidable inpatient days.
Not only will these efforts improve revenue cycle efficiency, reducing denials and streamlining admissions and discharge processes will also ease patient financial worries and enhance the overall healthcare experience.
RevSpring Can Help
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