CMs facilitate managed care cooperation
But they draw the line at direct patient access
Although her facility’s in an area with only about 35% managed care penetration, Toni G. Cesta, PhD, RN, director of case management at Saint Vincents Hospital and Medical Center in New York City, already has laid the groundwork for developing cooperative working relationships with managed care organizations.
Cesta’s first step was to provide office space at the hospital for the managed care representatives. "That was a big issue for us — what were the costs and benefits associated with making space and resources like telephones and computers available to them?"
Ultimately, Cesta concluded that having the managed care reps located together near her own case managers would create a more positive atmosphere and contribute to better working relationships between the two groups. "We looked at our contracts to see if we had agreed to provide space, and there wasn’t anything there," she says. "But it seemed like a smart business decision."
Another move designed to foster closer cooperation was inviting the managed care representatives to monthly staff meetings. Cesta notes that she has 30 case managers, "so it’s a large group for them to get to know. We bring them in to the staff meetings so they can put names and faces together. I really make an effort to have a collegial relationship with them, because that gets you a lot further than an antagonistic one."
Even so, there are some things Cesta won’t allow. Chief among those is letting managed care representatives talk directly to patients. "I really felt that would cause a lot of stress for the patient," she says. "Having all these different people coming in and saying I’m the case manager’ would be very confusing and intimidating. It’s really not appropriate." Managed care case managers are allowed to look in the patient’s medical record.
Overall, Cesta’s been pleased with having managed care case managers located on-site in her hospital. Because their primary function is utilization review, having them at St. Vincents saves her case managers from making time-draining phone calls. On the other hand, there’s always a potential danger in having managed care personnel be physically present at a facility. "It could potentially result in more denials," she says. "I can’t say for a fact that that’s happened, though. There’s always a risk when you have people on site looking in your medical records."
For more information, contact Toni G. Cesta, PhD, RN, director of case management, Saint Vincents Hospital and Medical Center, 153 West 11th St., New York, NY 10011. Telephone: (212) 604-7992.
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