CM/access combination may reduce denials
In response to the need for clinical expertise at the point of service, the consulting company Cap Gemini Ernst & Young works with providers to build in a case management function at the front end, says James Witt, MBA, RN, a senior manager who works out of the firm’s Chicago office.
Typically, the access nurse is assigned to patient access or registration and reviews admissions for clinical appropriateness. Sometimes, the nurses are involved in precertification and sometimes not, Witt says. In the recent past, he notes, his advice has been to integrate regular case managers into the access area, viewing that department as "another patient area, like cardiology or orthopedics.
"The value of doing that is that it brings a broader perspective to access than if [upfront case management] is done by a separate access nurse, who sees just the access function," he explains. "I have also recommended to clients that they rotate case managers through the access department every three to six months. Usually I recommend rotating once or twice a year."
Witt says he believes it’s good policy in general to rotate case managers from practice to practice. "They can certainly have a home service, but it helps to move people around occasionally," he explains. "This is particularly good when case managers have not had direct exposure to access. Moving them in for a stint really helps them understand utilization issues [and] helps identify early if a patient is high-risk. It’s getting the discharge plan on the way in the door, or sooner," he says. Rotating case managers through access helps them see access as a piece in the continuum, not a distinct function, Witt points out.
His experience has been that case managers typically "really like or really don’t like" working in access, he says. "[Access case management] is not as relational, but people who enjoy utilization management and payer contact really like it. Others, who are focused on a specific patient population, seem not to like access as well, particularly if they have a specialty such as obstetrics."
Although at present it’s exemplified by a relatively small group, Witt suggests the industry trend is to focus more on the access area as part of the case management design and to begin the process at the point of entry. The result, he says, is good for the patient and the balance sheet. "My general impression," he adds, "is that there is a measurable decrease in payer denial when case management is firmly in place in access, because of precert issues and also because it facilitates a better level of care."
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