Partners in HIGH FINANCE A solid relationship between case management and revenue cycle management can translate into better care and a healthier bottom line.
5 Editor Elizabeth Page Contributing Editors Pamela Parker with Daybreak Ventures Sean Muldoon, MD Richard C Senelick, M.D. with Healthsouth Art Director/Graphics Dustin Smith
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A flame represents the inception of something new, a sign that the perfect conditions have aligned to create light. But how does the flame maintain its resilience? The light will continue to burn bright only through a chain reaction- a pathway- whereby both internal and external forces unite to nurture its brilliance. In June 2013, shine your light for case management at
CMSAâ€™S 23rd AnnuAl ConferenCe & expo in new orleAnS, lA.
This multi-day journey is the sole health care event designed to deliver clinical, professional, regulatory and personal growth for the present and future of cross-continuum case management. Whether your case management light has been glowing for years, your flame is brand new or you would like to generate a spark, a spot is waiting for you in New Orleans.
Schedule at a Glance event
Monday, June 24
7:00a - 5:00p
Registration CMSA Annual Meeting Awards Ceremony Lunch Symposia & Afternoon Sessions Keynote: Carl A. Hammerschlag Opening Night Event
7:00a - 5:00p 8:00a - 9:15a 9:30a - 11:15a 11:30a - 5:00p 1:15p - 3:15p 7:00p - 10:00p
Tuesday, June 25
Wednesday, June 26
Registration Morning Sessions Keynote: Jill Bolte Taylor Expo Hall Open & Lunch Afternoon Sessions
7:00a - 5:00p 8:00a - 11:30a 9:45a - 11:30a 11:30a - 2:30p 2:30p - 5:15p
Thursday, June 27
Registration Morning Sessions Expo Hall Open & Lunch Afternoon Sessions
7:30a - 5:00p 8:00a - 10:45a 10:45a - 2:30p 2:30p - 5:15p
Registration Expo Hall Open Keynote: Mike Rayburn 2 | C a s e m anagementconnector.com Sessions
7:30a - 1:00p 8:00a - 10:15a 8:00a - 10:15a 10:15a - 2:00p
Friday, June 28
On any given day, the Soldiers of the Fort Hood Warrior Transition Brigade are undertaking a number of medical appointments as they navigate the path to healing and transitioning back into the military or into the civilian world. Every step of the way, the Soldiers are supported by registered nurse case managers, who help coordinate the best care available for wounded warriors. To the Soldiers of the Warrior Transition Brigade, or WTB, the nurse case managers are advocates, supporters and friends, who make sure the medical providers and the military chain of command are communicating clearly regarding the wounded warriors. "Our job here as the nurse case managers, is basically to coordinate all medical care so there's a continuation of treatment for these guys
and that everybody is on the same page," said Cynthia Basham, a registered nurse case manager with Company C, 1st Battalion, WTB. At Fort Hood, there are approximately 45 nurse case managers. Each nurse has approximately 20 Soldiers who they work with. "They're assigned one nurse case manager, who they can come to anytime with their medical issues," Basham added. "Once they report those, we coordinate with their PCM (primary care manager) and we contact their specialty provider, so they do get the best care." "We keep communication open to take care of the Soldier," added Carmen Boudreaux, a registered nurse case manager with Company D, 1st Bn., WTB. casema n a g e m e n t c o n n e c t o r . c o m |
But the nurse case managers take on a constantly evolving role with the Soldiers they work with. Boudreaux said she sometimes acts as a surrogate mother to young Soldiers who are hundreds of miles away from their families. Other times, she helps Spanish speakers understand their treatments or notes by translating information into their primary language. She said each part of her job is something she cherishes. "For me, it's helping the Soldiers that are coming back from battle. They have a lot of issues," Boudreaux said. "I'm so glad I can be there to help, not only them, but their families." At one time, Boudreaux was a nurse in a psychiatric unit. She said she often saw former service members in the unit, who were still dealing with the memories of Vietnam. "I'm working in this program now and I look back and I'm amazed at how much help the Soldiers have now," she said. "There are a lot of programs out there for them. All they have to do is request the help and we're going to provide for them. We are taking good care of the Soldiers." The nurse case managers include both civilians and Soldiers. Lt. Col. Selina Williams, chief of WTB nurse case managers, came to the unit about five months ago after working as an operating room nurse at Carl R. Darnall Army Medical Center. "It's just been fun and rewarding to make sure that we provide the Soldiers with everything the Army has to offer them. Whether that is medical benefits, or health and welfare benefits, I was just happy to be here to support that as a leader," she said. All levels of leadership of the WTB work with the nurse case managers and doctors to address any issues that arise with the WTB Soldiers and remain proactive in their treatment. To do this, the nurse case managers need to be tied in with the Soldiers and their families. "The key thing is trying to create that bond with these Soldiers and make them feel comfortable enough so they can discuss their issues, mentally and physically," Basham said. The wounded warriors always have access to a nurse case manager, Williams added. 4 | C a s e m anagementconnector.com
To the Soldiers of the Warrior Transition Brigade, or WTB, the nurse case managers are advocates, supporters and friends, who make sure the medical providers and the military chain of command are communicating clearly regarding the wounded warriors.
"There's always a nurse case manager available, 24/7, on weekends, on holidays, someone is always available," she stressed. She added that she was amazed by the work the nurse case managers do on a daily basis. "They put a lot of work into the Soldiers," Williams said. "They don't just sit down with them and say 'have you made your appointments?' This job is totally different than any other nursing job out there. Here, you're involved 24/7." But the nurse case managers wouldn't have it any other way. "To me, this is very rewarding," Basham said. "I get to give back to those that are fighting for my freedom and my family's freedom."
Partners in High Finance A solid relationship between case management and revenue cycle management can translate into better care and a healthier bottom line. As hospitals look for ways to improve the quality of care while also boosting revenue, the case management and revenue cycle management (RCM) groups are partnering more frequently. The functions that fall within case management vary by institution and how the group interacts with RCM depends largely on which responsibilities are in case management’s bucket. Because connections to RCM differ so widely, Steven L. Robinson, MS, PA, RN, CPUR, senior director of clinical documentation improvement (CDI) solutions at Maxim Health Information Services, says case management might have a huge link to RCM in one hospital but little direct influence in another. The two groups will always have an indirect relationship, though. “For instance, some case managers take on the role of the clinical documentation specialist or utilization review or looking at denials,” says Robinson, adding that at least one-half of all CDI programs are housed in the case management department. In that scenario, case managers are by default a direct part of the front-end revenue cycle. Steve Everest, executive vice president of Prognosis Health Information Systems, says the healthcare ecosystem is evolving, leading to a shift in the roles played by case management and RCM as well as how those responsibilities fit together and overlap. “As the industry changes and as the landscape changes a little bit with federal funding, case management is being pushed toward understanding the revenue cycle pieces,” he says.
A Shift in Roles In the past, case managers focused predominantly on the clinical aspects of a patient’s visit. However, today they’re increasingly being drawn into discussions about copays, coverage levels, and a patient’s ability to pay. “The smart hospitals are
the ones that are doing that work ahead of the game,” Everest says, meaning the case management team is involved in making sure the current financial picture is what the hospital wants while at the same time ensuring patients get the clinical outcome they need. “We see that line between pure case managers and pure revenue cycle people blurring, and we see people wearing both hats.” Based on her experience working in the revenue cycle, Carla Engle, MBA, director of product management at Emdeon, says case management’s role was broader several decades ago. “They were being charged with controlling cost by improving quality,” she notes. Over time, case managers narrowed their focus to utilization review and discharge planning. The pendulum now seems to be swinging back the other way, and case management is once again taking on a wider role. “I see case management really working in all aspects of the revenue cycle,” says Engle, who lists five primary areas where it has the greatest impact: preadmission, admission, concurrent review, discharge, and postdischarge. “There are things that case management does that touch all of those steps.” The case management team may have strong ties to RCM, but it’s just one group involved in daily decision making, says Diane L Reidy, RN, BSN, MN, MHA, director of the clinical case management department at Lyndon B. Johnson General Hospital in Houston. “We interface with coding; we interface with physicians. There are several departments we work with on a regular basis,” she explains. Any time a change occurs, such as when new computer programs are deployed that impact the workflow between the functional groups, Reidy says her team meets with RCM and any other affected groups to proactively discuss how they can best work together moving forward. The conversations focus on casema n a g e m e n t c o n n e c t o r . c o m |
a “let’s talk about what’s working and what’s not” approach, she says. The touch points between case management and RCM begin in the preauthorization phase, where Everest says healthcare organizations are increasingly interested in confirming benefit levels as well as a patient’s capacity to pay. The mission to be more proactive in determining a patient’s financial picture is being joined by the hospital’s desire to ensure it has the appropriate facilities and equipment for proper treatment. It’s all about the type of patient, according to Everest. “Who’s their payer? What does that payer expect? And what will the payer tell us about the patient up front before they darken our door?” he says. Outside the emergency department (ED), where preauthorization is moot, the emphasis is on being proactive. “Case managers are expected to take a role in that and bond with the revenue cycle folks to figure those things out,” Everest says.
Medical Necessity Upon admission, the collaboration between case management and RCM ramps up, says Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, an ICD-10-CM/ PCS trainer and director of HIM solutions at AHIMA. “That’s when the determination is made if they meet inpatient medical necessity or if they’re an outpatient,” she says. While the case manager generally is not the sole person determining medical necessity, it’s another link in a chain of instances where case management and RCM work together. “Sometimes the patient may come in as an outpatient and later get converted to an inpatient. Again, that needs to be looked at,” says Endicott, adding that as the patient moves through the process, several factors will affect how much interaction is necessary between case management and RCM. “The more complicated cases will require increased interaction between the case managers and physicians to ensure that the patient’s treatment plan is carried out appropriately so the patient receives the best quality of care,” she notes. Rather than throwing case management and RCM together and simply telling them to collaborate, Engle says everyone benefits from a carefully constructed plan. “I think 6 | C a s e m anagementconnector.com
there needs to be a clear protocol established about where case management gets involved,” she says. Engle encourages healthcare organizations to develop policies to define case management’s role and where it intersects on both the clinical and financial sides. This will address case management’s exact responsibilities and identify potential gaps in its relationship with other departments. “The hospitals that have the best practices have a very clearly delineated process about where case management is involved on the inpatient and outpatient perspectives,” she says.
Record Reviews Establishing a process that includes a thorough review of records is crucial to a strong and proactive communication stream between case management and RCM. Because the majority of inpatient admissions are based on diagnosis-related groups (DRGs), Robinson says it typically falls to concurrent reviewers to identify which working DRG is assigned. As case management and RCM work more closely together, case managers are increasingly involved in that process. “If case managers take on the role of the CDI specialist, they will assign that working DRG or initiate a discussion to clarify which DRG should be assigned,” Robinson says. The case manager then follows the progression of a patient’s symptoms and diagnoses. If the physician hasn’t provided enough clarity, Robinson says the case manager would then query him or her on specific causes as needed. Records review—and how case management and RCM work together to ensure documentation addresses the needs of both groups—isn’t something you can set and forget, Reidy says. “Most of our processes have changed because in the latter part of 2010 we implemented an electronic medical record system,” she says. “[As a result], you have to look at everything you’ve been doing in the past and ask why you did it that way. It’s one of the things we’re still polishing.” Determining which points will be reviewed in the medical records doesn’t involve just case management and RCM. Endicott recommends other functions such as CDI and utilization review also take part. “And it’s not just one person making that decision [of what to review],” she says. “It’s having
the experts that know the revenue cycle work with those in case management to determine that checklist.” Such a process can ensure the necessary information is present and accounted for in the file. For example, are admit orders where they need to be? Were all the complications documented? Is the correct discharge disposition in the chart? “It’s a team approach,” Endicott says. “It’s not just one department doing it.” The proactive component to records review is perhaps the key benefit to both case management and RCM. “I think the biggest thing is just preventing stoppage from happening on down the line,” Engle says. Rather than expend energy with postdischarge denials and appeals on the back end, thorough reviews by both groups can help business operations flow smoothly. That’s a plus for the administrative process as well as the hospital’s revenue stream. “As they’re doing concurrent record review, they’re really making sure a denial is not going to happen,” Engle explains. Where do medical necessity and length-ofstay approvals factor into the equation? Engle says the majority of denials she witnessed during her work as an auditor related to medical necessity. “I think case management plays a huge role in ascertaining medical necessity right from the get-go,” she says. “They make sure there aren’t going to be any problems. It prevents those denials on the back end.” According to Engle, concurrent reviews while the patient is still in-house translate to fewer appeals and denials being triggered. RCM teams often spotlight high-utilization cases that require more resources and longer stays. “Those are the things that, as a case manager, you have to find the balance between the financial side, longer length of stay, and higher utilization of resources vs. patient care,” Engle says.
Location Matters When it comes to medical necessity and length-of-stay approvals, Everest says urban environments typically lend themselves to higher levels of proactive collaboration between case management and RCM. For example, a client in a large Oklahoma city preauthorizes every account because it
makes sense from both the case management and RCM perspectives. “They make sure that they run credit checks on the patient because they are an elective surgery facility,” he says. This strategy also saves the hospital from going through the steps involved in registering patients and preparing them for a procedure only to find out they can’t afford their payment portion. “We’re seeing the case managers get involved with that process— that proactive, up-front process—before the treatment begins whenever they can,” Everest says. The approach in the community hospital market in rural America differs from that of urban facilities. In the rural setting, Everest says the group of physicians practicing nearby is often quite small, and the patient population being served is typically a known quantity. “It’s almost a given that we know what kind of patients this physician is going to treat, and we know with a high level of probability what their outcome is going to be,” he explains.
Working Arrangements Discharge dispositions and final diagnoses often are understood early in the process. In those cases, Everest says case management and RCM may work together in a unique fashion. “Some of our clients are opting, if it’s not a significant outlier in terms of dollars, to absorb [the cost] rather than irritate the local community,” he says. Identifying the number of days allowed in the hospital is generally a function Robinson sees in the realm of case management. “That used to be the old utilization review function, but now it’s largely been incorporated into the role of the case manager,” he says. If they’re not able to identify the length of stay up front, sometimes they “will also have the responsibility of calling the insurance company to see if the patient is allowed extensions on their stay,” Robinson says. Medical necessity, length-of-stay approvals, and the actual duration of the patient’s stay directly impact the bottom line in the long term. “Revenue cycle does have ultimate responsibility for those functions,” Robinson says.
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