Centers for Medicare and Medicaid Services (CMS)
RSSArticles
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Not All Capitated Payment Models Work
Nearly a decade ago, Maryland experimented with a global budget payment model for rural hospitals. The plan was to give them a set amount of money, called Total Patient Revenue, to improve their efficiency. But it did not quite work out. ED visits dropped 12%, and non-ED admissions declined 23%. But there was little incentive for the hospitals to collaborate with community providers to improve patients’ health. Instead, the hospitals just reduced overall services.
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Health System Reaches ED Visit Reduction Goals by Focusing on Frequent Users
When a five-year, federally funded demonstration project began in New York, the goals were lofty: reduce preventable readmissions by 25% or more. NYU Langone Health achieved this goal through identifying frequent users and working with them through a targeted case management approach.
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Observe and Take Notes, But Try Not to Judge
Health advocates can collect comprehensive and important information about a patient’s daily life and share the findings with primary care providers. But it can be challenging to walk through someone’s home and listen and observe without judging and wanting to take immediate action.
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How Health Advocates Work With Patients, Case Managers, and Other Resources
A health advocate’s role varies, depending on the patient populations and goals. Health advocates collaborate with the patient’s healthcare team and help everyone reach an agreement on the care transition or any necessary changes.
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Privately Paid Case Managers Serve as Patient Health Advocates
Case managers work with patients across the care continuum, and their roles and titles vary. But one of the lesser-known models for case management is in private pay, where they are known as health advocates or patient advocates. It is a growing field, as patients and families often find it difficult to navigate the complex healthcare continuum. Health advocates provide case management-type services with their chief goals related to patients’ needs.
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Case Management’s Role in Managing Denials and Appeals in the New Healthcare Environment
Revenue is defined as the sum earned by the provider, measured in dollars. The revenue cycle is defined as the series of activities connecting the services rendered by a healthcare provider with the methods by which the provider receives compensation for those services. Case management plays an integral role in managing revenue and the revenue cycle in the denials and appeals processes. This month, we will discuss the case manager’s role in the revenue cycle as it relates to the management of denials and appeals.
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Avoiding Denials for Transitions of Care
Too often, a patient’s claim for post-acute care is denied for reasons that are entirely preventable. This transition may include either rehabilitation or palliative services in a facility, ongoing outpatient therapy, or care provided at home. These authorizations are scrutinized closely by both payers and regulatory bodies, so it is critical that hospital case managers know how to avoid denials.
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Hospitals and Colleges Collaborate in Health Coach Training Programs
Some small-town hospitals and colleges have found a way to provide pre-med, nursing, and allied health undergraduate students with hands-on medical experience that benefits the community. The student health coaches perform case management-type services for at-risk patients. Called health coaches, these students learn skills years ahead of their peers. They receive college course credit and volunteer or internship experience. And, they contribute to positive health outcomes, including keeping patients out of hospitals and EDs.
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Medicaid Reimbursement Change Increases Interbirth Intervals Among Teens
After changing its Medicaid policy to provide reimbursement for immediate postpartum long-acting reversible contraception (LARCs) separate from the global labor and delivery payment, South Carolina saw an increase in immediate postpartum LARC initiation and increased birth spacing among young women.
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Reducing Long-Term Patient Costs Requires Going Above and Beyond
Case managers in hospitals and community settings often have to go beyond point of care activities to help patients make significant improvements in their health and healthcare costs. This is particularly true with patient populations experiencing major barriers to maintaining disease control and health improvement, including housing, food access, transportation.