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Recognizing that chronically ill patients benefit from care management beyond the walls of the hospital or their physician's office, Middlesex Hospital in Middletown, CT, has created The Center for Chronic Care Management, which offers four National Committee for Quality Assurance- (NCQA) accredited disease management programs to help patients manage their conditions.
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By conducing real-time concurrent denials management, Jewish Hospital and St. Mary's Healthcare, a not-for-profit health care system in Louisville, KY, keeps its average denials rate below 1%, consistently exceeding the hospital's goal of a denials rate of under 2% for commercial patient days, including Medicare managed care patients.
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As reimbursement shrinks and health care providers tighten their belts, hospitals need to take a proactive approach to denials to make sure they get paid appropriately for the care they provide, experts say.
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If there are any doubts that improving patient flow also enhances patient safety, the recent experience of the ED at Enumclaw (WA) Regional Hospital should dispel them.
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By redefining the roles of case managers and social workers and working with physicians on patient throughput and length of stay, Fauquier Hospital in Warrenton, VA, significantly reduced its Medicare length of stay by almost a day and decreased the revenue lost because of denials by medical necessity by 70%.
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By taking a proactive approach to patient status and instituting a series of checks and balances, Good Samaritan Hospital in Dayton, OH, keeps denials at a minimum.
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When CIGNA members being treated by Piedmont Physicians Group in Atlanta are high-risk or noncompliant, Jennifer Farlow, RN, BSN, clinical care coordinator, contacts them and helps them get back on track for regular visits and recommended tests and procedures.
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Who knew what when? At times, you can be put in a tough position because of what a worker tells you. "We are not safety and we can't discipline, so employees tend to tell us more than they would tell others," says Susan L. Zarzycki, RN,COHN,CM, an occupational health manager at Finch Paper LLC in Glens Falls, NY. Here are some common scenarios and how to deal with each:
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As health care organizations tighten their belts to deal with today's health care environment, case managers report working harder with fewer raises and benefits. But, there is hope on the horizon as new opportunities open up for case managers under health care reform, experts say.
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As talk of reimbursement reform and pay for performance escalates and health care stakeholders look at ways to improve patient access and outcomes while reducing waste and costs, payers and providers are joining together to create accountable care organizations (ACOs), partnerships that agree to be accountable for the quality, costs, and overall care of a patient population.
