CM finds its way into state/federal laws
Survey: More than 2,000 statutes refer to CM
In preparation for the launch of its case management program accreditation last year, the American Accreditation Healthcare Commission/ URAC in Washington, DC, took a close look at how case management is regulated at both the state and federal levels. It found references to case management in statutes in all 50 states — more than 2,000 references, to be exact, according to Gary Carneal, JD, MA, president and chief executive officer of URAC.
"We did a search using Lexis-Nexis, a computer search tool used for legal research, and drilled it down and focused on the health application of case management by using three key terms — insurance, health, and medical — along with the terms case management,’ case manager,’ or care management,’ and found that these terms are used frequently within state regulation," he explains.
Carneal updated his search this April with the following results:
• 2,102 state statues refer to case management.
• 840 state statutes refer to care management.
• 377 state statutes refer to case manager.
• 3,123 state statutes refer to at least one case management term.
• 1,337 state statutes refer to case management and either insurance, health, or medical.
• 282 state statutes refer to care management and either insurance, health, or medical.
• 296 state statutes refer to case manager and either insurance, health, or medical.
• 1,756 state statutes refer to at least one case management term and either insurance, health, or medical.
In addition, Carneal says case management is referred to 179 times in state workers’ compensation codes and 569 times in state disability statutes.
"When you begin to aggregate this on the state level, you can see that every state has at least one reference to the term case management.’ Does this mean more regulation of the case management profession is coming? Perhaps not, but certainly these statutes impact how you get funding and how you spend your time as a case manager," he says.
As he looked at the state statutes, Carneal was able to draw the following four conclusions:
• Most case management laws are oriented to social service and public welfare issues.
• There is no enabling legislation for case management organizations similar to legislation for health maintenance organizations or utilization management organizations.
• A typical reference to case management is a simple identification of case management as covered or not covered by a particular program.
• Most state statutes that refer to case management do not address health benefit issues directly.
On the federal level, Carneal found 125 statutes that refer to case management and either insurance, health, or medical. Those statutes also seem to fall primarily in the areas of social service or public welfare programs. Federal programs with statutes or codes referring to case management include the food stamp program, immigration (refugee assistance), medical and dental care for the armed forces, Indian health care, veterans’ benefits, housing assistance, foster care and adoptive services, medical assistance and Social Security provisions, and child mental health and abuse prevention.
Perhaps even more revealing is that Carneal found 2,405 federal and state court decisions that refer to case management and either insurance, health, or medical.
"Further searching narrow[ed] that figure down dramatically to 12 cases where case management’ or case manager’ is a core term," he says.
Court decisions indirectly regulate care
Carneal explains that case law can establish principles that affect how case managers do business. For example, one ruling came out of a workers’ compensation appeals panel in Tennessee. In that case, an injured employee had a work-related low-back injury and went to his physician for treatment.
"The payer was not clear that the employee was seeking treatment specifically for the work-related low-back injury and deauthorized the original physician and assigned the employee a new physician," he says. "The appeals panel looked at the workers’ compensation statute and ruled that a workers’ comp carrier is not allowed to deauthorize a physician without just cause and pointed out the injured employee should not bear the burden of establishing reasonableness of care. Clearly, this is an area where the case manager might be expected to be involved."
In Minnesota, a young man with Tourette’s syndrome and depression sought state disability services, specifically case management education and support services, under a state statute designed for individuals with mental retardation. "The court ruled that the state had to extend case management services based on the facts of the case. What is important here is that courts are sometimes used to decide whether case management services are provided," says Carneal.
"In this way, court decisions are an indirect way in which case management services are regulated," he explains. "This is where accreditation processes can step in and provide case management organizations with a set of rules and guidelines for how to operate." (For a step-by-step guide through the URAC accreditation process, see p. 120. For more discussion on how to sail through accreditation, see Case Management Advisor, December 1999, pp. 181-184.)
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content