Hospital Case Management – February 1, 2018
February 1, 2018
View Issues
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When Managing Denials, the Best Defense Is a Good Offense
Denials represent a significant amount of lost revenue. Case managers should take an active role in preventing and managing denials.
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Types of Case Manager Reviews
This chart shows the types of payer reviews case managers typically perform.
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How to Avoid Four Types of Denials
Case managers must take a proactive approach to reducing the denial rate — and the best way to do it is to prevent the denial.
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Be Knowledgeable About Hospital’s Payer Contracts
To prevent denials, case managers must know the requirements of each individual payer. But at some hospitals, the finance and/or managed care departments don’t provide case management with the utilization review section of the contract where the rules are outlined.
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Large Caseloads Make Denial Prevention Difficult
Hospitals that pile task after task on case managers and assign them large caseloads are unlikely to effectively manage denials.
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Revenue Cycle Team Optimizes Reimbursement
If a hospital doesn’t have a revenue cycle management committee, case managers can approach leadership and suggest that they propose that the hospital administration create a committee to review all contracts and denials.
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Patients Threatened by Gaps in Care When They Change Settings
Patient safety and quality of care are threatened when patients move from one setting to another, but there are strategies that can address those gaps in care.
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Hospital Standardizes Debriefing After Critical Events
The maternal and fetal medicine team at Sharp Grossmont Women’s Health Center, affiliated with Sharp Grossmont Hospital in La Mesa, CA, improved quality of care recently by implementing a standardized debriefing process for critical events.