Case Management: The Healthcare Reimbursement

Case managers also provide support and information to patients and their families. Next, is utilization review. `Its main objective is to review each case and determine the most appropriate level of services, the most appropriate settings in which the services be delivered, the most cost efficient methods for care delivery and the need for planning of subsequent care. Other methods used for utilization and control are choice restriction and practice profiling' (Douglas, 2003, p.328).

Case Managers have a challenging job, often dealing with patients, community agencies and facilitating their hospital discharge to the next level of care. They collaborate and communicate with the entire healthcare team and mostly with the patient during the hospitalization process. They act as support for all stakeholders to achieve positive patient outcomes. In this paper, I will be interviewing Ian Mopas, who is a Patient Care Coordinator at Kaiser Permanente in Redwood City about his education, work training, goals, and objectives as a Care Coordinator, and his responsibilities in his organization.

According to an article published in Case Management Advisor (2008), education assists case managers with being as knowledgeable as possible to identify and coordinate all the resources that their patients need and continued education is an ethical responsibility of a case manager. The article also suggests that advocacy is an ethical responsibility of a case manager. When advocacy is forgotten ethical issues occur. Fraser and Strang (2004) explain that case managers must be given the tools to allow them to function in their role with confidence and competence to act as strong advocates for their patients. Support for decision making is also a key component of case management. Coffman (2001) offers key points from The Code of Professional Conduct for Case Managers advising that case managers are guided by the principle of autonom. Case mangers achieve autonomy through advocacy. If case managers are expected to function with complete autonomy, then case managers require the assusrance that their leader ship will support them when difficult decisions have to be made, (Fraser and Strang, 2004). The concept of employer employees explains that by involving employees in developing the mission and values of the company, this allows employees feel empowered (Porter-O’Grady & Malloch, 2007). By allowing the case manager to be part of the development of the

In order to, differentiate between utilization management and case management using the seven case management standards, it is first important to define each individual component. To begin with, a key component of quality and cost effective care is Utilization Management (UM). Utilization management is a way to assure that the appropriate care is medically efficient, a suitable use of health care services, proper procedures, and is applicable with provisions aligned in the health benefits plan. Case Management engages quality services in a timely coordination of patients’ specific needs in an approach that promotes positive outcomes by means that are cost effective. Case management may be developed during a single health care setting that may then transition throughout the care continuum. The seven standards are key components that described to maximize benefits and minimize the opposition.

The case management process consists of five parts: assessment, treatment planning, linking, advocacy, and monitoring. It is not a linear process and does not follow the order it is written up. There may be some back and forth and returning to certain points.

In the healthcare environment, the challenges that providers face are revenue shortfalls due to insufficient payments from the reduction of Medicare reimbursement rates (Shi and Singh, 2015. p238). Payers that have employment-based insurance are charged extra to cover the remaining balance. This process is called cost shifting. In some healthcare systems, the relationship between reimbursement reduction and cost shifting is correlated in an inversely proportional trend. As the decrease in reimbursement from public insurance such as Medicare and Medicaid, the method of cost shifting would increase.

Case management is a continuous balancing act of judgment calls, making ethical choices, getting along with coworkers, and following legal protocol. It is the duty of the case manager to know how to develop a relationship with both clients and coworkers while still maintain their professionalism. The healthcare professional must always leave their personal opinions at home and provide the same quality of care to all their clients regardless if they have different views, religion, sexual orientations, or cultures. The case manager needs to ensure that the client’s concerns will be put first no matter what, and should also clarify that the as the professional he or she will do all that is necessary to provide the best quality of care to their client.

Case management is not a lifetime service. With the lack of funds available for all the clients in need of service often times termination of service is the only option. In this paper we will examine the process a case manager goes through when termination of services occurs. We will also discuss how independent care will help in continued client growth.

The reimbursement method used at St. Anthony’s hospital is quite distinct depending on the party doing the payments. Payments are received from Medicare, Medicaid, private insurers and also directly from patients. The party responsible for Medicare payment is the Federal government and it offers payment mainly for the elderly. With the Medicare payment, hospitals receive a flat fee depending on the case. According to Gee (2006), most hospital revenue has declined because of the revised payment set by the Diagnosis-Related Groupings. The fee for most cases varies according to the Diagnosis-Related Group (DRG) it can be classified under. For example, Medicare pays only a fixed amount for an elderly patient suffering from pneumonia regardless

Today almost every major health care organization has a case management program managing and directing the use of health care services for their clients. Also, case management by payer organization is recognized as external case management (Jacob & Cherry, 2007). Hospitals recognized the need for the case management model in the mid-1980s to manage the lengths of stay of hospitalized patients and the treatment plans (Jacob & Cherry, 2007).

Lights of Zion will hire an experienced case manager/“reentry counselor,” to assist reentry experience from prison to sustained employment. The case management begins with a comprehensive individual assessment. From this assessment, a service plan is created that manages every aspect of the participant’s reentry program. The case manager monitors the plan, ensuring that all goals and objectives are being reached. Case manager Service will also participate in client recruitment, services, mentorship and job training and placement.

This type of funding helps determine hospital budgets and hospital management allocate resources within organization.

In Europe a detailed questionnaire about basic ICU characteristics and ICU reimbursement practices was developed and send to members of the European Society of Intensive Care (ESICM) using a comprehensive web-based questionnaire [ ]. In total 447 responses could be analyzed. Of these, 51.5% stated that their ICU received detailed financial information; however, only 15.4% of respondents could identify each cost item for each patient. A majority of respondents (77.6%) stated that their unit's reimbursement system was included in the hospital reimbursement. ICU reimbursement systems were most commonly based on previous year's ICU expenditure (51.0%) and diagnosis-related group weights (36%).

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Pursuant to the terms of the Agreements, the Account(s) is debited for certain monthly services fees in exchange for services provided by Rabobank and BMS. As noted above, the services provided by BMS include: (1) together with Rabobank, banking services, including the management of the chapter 7 accounts required in this Case, deposit management, monthly statement processing and production, interim statements, couriers, checking, wires, electronic UST reporting, online banking and transfer services, collateral tracking services, and expanded FDIC coverage; (2) case management technology services, including access to proprietary software licensed to the trustee by BMS; automated data and document delivery and management; electronic court filing (ECF) and retrieval; processing and transmission services; UST customized reporting software, and a variety of other document preparation, claims management software, and third party software from such providers as Microsoft and Adobe; (3) hardware, including computers, networking equipment, printers, and scanners, as well as installation, repair and maintenance services , and (4) training and support services, including software training, information technology support, and special project requests.