Rely on past experience in project cost of care
Networking can help you fill in the gaps
A case manager’s past experience and knowledge are invaluable when projecting the cost of care, says Joann Milne, RN, BSN, CRRN, PHN.
"The real key is not to be afraid to project the cost of care and to get as accurate as you can. Often, for case managers, their years of experience give them the ability to get very close to actual claims when they do their cost projections, says Milne, assistant vice president of medical management programs with IOA Re, with headquarters in Plymouth Meeting, PA.
Look at the type of care and how complex it is. Take into account the complexity of the individual and the length and type of care that particular person will require.
Know what your company’s risk exposure is. What is the contract period? What services are covered? Is there a reinsurer, and when does it kick in?
For instance, if you assume care of a 9-month-old with a hypoplastic left heart in November, and the contract period runs January to December, you need to project the cost of care from the date of birth to the end of December, and then for the next 12 months.
Take the cost of past care into account. Typically, by the time a case manager gets involved, the patient already has received care. Talk with the claims examiner to determine what claims have been paid to date.
Look at whether care is being done in-network or out of network. This information usually is available from your supervisor or from the contract manager. Know if your provider contracts call for care on a per-diem basis or if the company is being billed for a percentage off the charges. Consider what treatment/procedures still need to be done for the patient to obtain a state of wellness.
Review your cost projections regularly. If you see something that has changed, make sure the administration knows that the costs are expected to go up or down and by what amount.
"Cost projection is very fluid," she adds.
Network with other case managers to share information on the anticipated clinical course of the disease or condition, average length of stay, and outcomes.
Disease management companies are excellent resources and can give you information on projected clinical courses and average costs.
Look within your organization for resources. For instance, the claims staff and medical directors have a good grasp of the cost of care. Your financing and contracting department also are good resources. MillimanUSA (formerly Milliman and Robertson) publications are another good source for information. The Redbook provides valuable information to help you determine the cost of pharmaceuticals.
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