Hospital Management
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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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Nursing Innovation Is Underused and Can Be Leveraged for Career Advancement
Nurses are gaining more stature as potential leaders in healthcare, and much of the innovation in healthcare will come from nurses in the future. Hospitals should work to leverage the innovative potential of nurses, and nurses in the quality field should look for opportunities to advance their careers through this increasingly available pathway.
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Helping Patients Find Motivation to Make Changes
Eat healthy, exercise regularly, and sleep more are healthy goals case managers and nurses reinforce to patients. But case managers often have difficulty living up to their own advice when hectic daily schedules leave little time for healthy pursuits. These goals are so hard to pursue because the benefits are so long-term.
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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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Patient Activation Is a Health Promotion Method That Works
Case managers continually learn new methods to educate and engage patients. The key is to find the right method for case managers to achieve their patient education goals. The patient activation measure is based on the theory that there is a great deal of variation in patient activation/engagement in a patient population. Some patients need more support, and should be evaluated to see what works.
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The Inner Workings of a Health Coaching Program
Hospital case managers and others interested in extending case management through the use of student health coaches can implement a health coaching program with a local college. Both hospitals and colleges can benefit from the collaboration.
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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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Appellate Court Rejects Loss-of-Chance Argument for Patient Who Suffered Stroke
This case reveals a potent defense for physicians and care providers: A patient must prove causation when raising a malpractice allegation. A plaintiff must prove that the physician or care provider’s conduct is a substantial factor in causing the harm, which means that it must be more than a remote or trivial factor. However, it does not have to be the only cause of the harm. If the harm would have occurred without the physician or care provider’s conduct, then the conduct was not a substantial factor in causing harm.
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Patient Loses Eye to Improper Sterilization of Surgical Equipment; Awarded $3.5 Million
The lessons from this case include the importance of proper sterilization, as well as the legal procedures and appeal options. The appellate court noted that the hospital did not dispute the possibility that a breach in the sterilization process had occurred; instead, the hospital focused its challenge on the fact that the patient had not presented convincing evidence demonstrating that the breach in sterilization practices had caused the infection.
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Future for Risk Managers Will Require Flexibility, Learning
Risk managers seeking to improve their careers must evolve continually with the changing healthcare landscape. There are new technologies to consider, along with value-based reimbursement models, that are dependent on quality patient outcomes. Healthcare delivery models continue to bring new and sometimes unfamiliar services and exposures to an organization.