CMs should give clients several options
New regulations from the Health Care Financ-ing Administration (HCFA) in Baltimore have made case managers more aware of the need to inform clients of their provider options even when those options may not be part of the case manager’s integrated system or network of capitated providers.
The new regulations established as part of HCFA’s Operation Restore Trust are designed to put an end to Medicare fraud and abuse and apply most directly to providers such as home care agencies. They do offer some guidelines for all case managers, however.
"Where a hospital or a group of doctors own a therapy facility or laboratory or medical supply provider or home health agency [to which] the case manager may refer a patient, the case manager must disclose the ownership to the patient when talking about provider options and also give several other options," says Valerie V. Parisi, RN, LNC, a legal nurse consultant and independent workers’ compensation case manager with ValPar Consultants in Doylestown, PA.
"And although the regulations apply to Medicare and Medicaid patients, I think that if you’ve begun to follow HCFA regs for some patients, it makes sense to follow them for all patients. I don’t think it’s necessary or even possible to inform clients of every possible provider available to them, but options should be given," she says. "Patients understand capitation. Case managers should make patients aware of capitated arrangements. And I think, ethically, case managers have the obligation to give patients a couple of choices, even if those options fall outside their network."
Perhaps the most important obligation case managers have is to explain the appeals process. "If you know in your heart there is a better provider or a better treatment for a particular patient, it is best to mention it to the patient and then explain the appeals process," Parisi says. "Tell the patient that the health plan is not denying care, just this particular treatment or provider, and that if they really want to try another option, they can appeal and ask for it. Sometimes, you get what you ask for."
She cautions that each state has different rules regarding gag orders. "There are several good Internet sites to help case managers keep up with changes in managed care legislation. Two I use are www.harp.org and www.hcfa.gov."
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