Consider hiring an internal case manager
Good communication is the goal
One way to smooth out problems with insurers is to have a managed care case manager on your staff.
The managed care case manager would be responsible for communicating with the managed care organization’s (MCO) case manager. Keeping the lines of communication open between the internal (hospice) case manager and the external (managed care organization) case manager ensures that both parties are in agreement about care, which will help prevent disputes over unauthorized care when the claim is submitted.
Just as admissions staff need an education in current MCO contracts, case managers must also have a working knowledge of contracts. The case manager acts as a link between the clinical activity in the hospice and the financial requirements of the managed care organization.
Key points an internal case manager must know about each contract include:
• Authorization process. The case manager should be clear about whom to call and when in the event that a patient requires care that is outside the agreed-upon care. Changes in care may occur when a physician, after consulting with a therapist, orders therapy services after admission.
• Required information. What information or documentation does the HMO or managed care organization require? Making sure a claim is accompanied by the proper documentation will also prevent delays in payment.
A common theme through all this is communication. From the time of admission, the admission staff need to tell the case manager which payer is responsible for paying for patient’s care, what level of care the provider was authorized to deliver, and whom to contact for further authorization.
Case managers should meet weekly
Meetings between internal case managers and external case managers should occur regularly, normally through weekly utilization review meetings where cases are discussed individually. These meetings also should include other clinicians — such as RNs, therapists, social workers, and chaplains — to provide needed background when discussing the change to a patient’s care.
How many case managers does a hospice need? Depending on the level of managed care in one’s market, the number of case managers needed might range from several full-time case managers to none. Hospices should be aware that as managed care becomes a larger part of their business, there is a greater need for a full-time case manager. The old model of using the director of nursing to track patients will only leave the leader of your nursing staff awash in paperwork in addition to supervisory duties.
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