Case Management

Mentor moment: Communication between physicians and case managers reduces patient risk

Case Management Weekly, September 1, 2010

Case managers continue to struggle with maintaining a balance between doing what is right for the patient and ensuring that their facilities receive proper reimbursement. RAC auditors or a third-party payer may not agree with their patient status decisions, which means their healthcare organization will end up providing free healthcare.

Software programs such as The Milliman Care Guidelines®and InterQual® Criteria, as well as Medicare regulations, help case managers and physicians determine the correct patient status, the appropriateness of continued stays, and appropriate discharges. These tools are only part of what is necessary for the decision-making process.

The key to determining appropriate patient status is considering patients’ physical condition and clinical picture. Remember that patients are either inpatient or outpatient; observation is a service not a status. Ongoing communication and collaboration between physicians, nurses, and case managers is essential to putting all the pieces together to do what is right for patients.

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