Case Management

Case Management Articles by Topic: Billing and Reimbursement

Sneak peek: Readmission penalties expected to affect two-thirds of U.S. hospitals

  • Case Management Weekly, Issue 47, November 21, 2012

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Sneak peek: One simple question about patients’ benefits coverage can eliminate big headaches

  • Case Management Weekly, Issue 46, November 14, 2012

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Case management Q&A

  • Case Management Weekly, Issue 46, November 14, 2012

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Case management Q&A

  • Case Management Weekly, Issue 45, November 7, 2012

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Case management Q&A

  • Case Management Weekly, Issue 43, October 24, 2012

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Tip: Query forms bridge the gap when coders, physicians speak different languages

  • Case Management Weekly, Issue 40, October 3, 2012

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Tip: Beware of improperly submitting provider liable claims

  • Case Management Weekly, Issue 28, July 13, 2011

    Don’t make the mistake of submitting a provider liable claim because a case doesn’t...

Sneak peek: Is improper billing inflating your readmission rate?

  • Case Management Weekly, Issue 28, July 13, 2011

    Hospitals may have a higher than expected readmission rate simply because they aren't properly...

Mentor moment: Provider-friendly change to tracking observation hours

  • Case Management Weekly, Issue 25, June 22, 2011

    In the July OPPS update, CMS made a very provider-friendly manual change to the section on counting...

Mentor moment: Communicating with physicians is the key to effective case management

  • Case Management Weekly, Issue 24, June 15, 2011

    Allow me to share a recent experience I had with a physician group regarding clinical...

Sneak peek: Investigate gray areas to improve patient status assignment

  • Case Management Weekly, Issue 21, May 25, 2011

    Not every patient status decision is difficult. Some are quite obvious.

Tip: Nursing documentation requirements for observation services

  • Case Management Weekly, Issue 19, May 11, 2011

    Nursing documentation for observation patients must reflect the assessment and reassessment of...

Sneak peek: Assign a surgery gatekeeper to ensure inpatient-only compliance

  • Case Management Weekly, Issue 19, May 11, 2011

    Most facilities do not have a process to check scheduled surgical procedures against the...

Former non-profit owner to serve 12 years for fraud scheme

  • Compliance Monitor, Issue 18, May 4, 2011

    Shirlene Reese Boone of Murfreesboro, NC, will serve 12 years in prison followed by three...

News: CMS releases report on RAC improper payments

  • Case Management Weekly, Issue 18, May 4, 2011

    CMS released a recovery audit contractor (RAC) update about total improper payments since the RAC...

Tips: Evaluate medical necessity early

  • Case Management Weekly, Issue 18, May 4, 2011

    An effective process for evaluating medical necessity of admission begins when a patient presents...

Mentor moment: CMS publishes IPPS proposed rule for 2012

  • Case Management Weekly, Issue 17, April 27, 2011

    This year’s proposed rule contains the widest variety of inpatient clarifications and...

News: HHS launches Community-Based Care Transitions Program

  • Case Management Weekly, Issue 8, April 20, 2011

    The Partnership for Patients is a national partnership that aims to save 60,000 lives by stopping...

News: CMS releases ACO proposed rule, seeks comments

  • Case Management Weekly, Issue 15, April 13, 2011

    The April 7 issue of the Federal Register includes the long-awaited proposed rule that would...

Tip: Determine patients' resources for postacute services

  • Case Management Weekly, Issue 15, April 13, 2011

    Understanding how Medicare pays for hospital services helps discharge planners counsel patients and...

News: CMS podcast addresses high-risk medical necessity vulnerabilities

  • Case Management Weekly, Issue 13, March 30, 2011

    CMS’ Medicare Learning Network® has released the first in a series of podcasts designed...

News: Special ODF to address inpatient quality reporting HAC measures

  • Case Management Weekly, Issue 11, March 16, 2011

    CMS has scheduled a March 21 Open Door Forum that will focus on the hospital-acquired condition...

Mentor moment: Medicaid RACs are coming...someday

  • Case Management Weekly, Issue 9, March 2, 2011

    CMS has instructed Medicaid agencies to develop Medicaid recovery audit contractor (RAC) programs...

Sneak peek: Deduct active monitoring time to bill observation appropriately

  • Case Management Weekly, Issue 9, March 2, 2011

    Observation services are a specific set of services provided to a patient while the physician...

Create a compliant condition code 44 process

  • Case Management Monthly, Issue 3, March 1, 2011

    CMS’ rules for properly applying condition code 44 are hard enough to understand, but when it...

Carve out active monitoring time to bill observation appropriately

  • Case Management Monthly, Issue 3, March 1, 2011

    Observation services are a specific set of services provided to a patient while the physician...

Mentor moment: Case management protocol is still debatable

  • Case Management Weekly, Issue 8, February 23, 2011

    CMS reiterated in SE1037 that inpatient screening tools may assist facilities in making patient...

News: CMS announces electronic data submission tool

  • Case Management Weekly, Issue 8, February 23, 2011

    CMS has announced its "esMD" (electronic submission of medical documentation) program...

Q&A: Backdating an inpatient admission

  • Case Management Weekly, Issue 8, February 23, 2011

    Q: A patient receives observation services following an emergency department (ED) stay, but the...

Sneak peek: Create a compliant condition code 44 process

  • Case Management Weekly, Issue 8, February 23, 2011

    Facilities that use condition code 44 often can take that as a sign that they have a poor inpatient...

Sneak peek: Deduct active monitoring time to bill observation appropriately

  • Case Management Weekly, Issue 6, February 9, 2011

    Observation services are a specific set of services provided to a patient while the physician...

Mentor moment: CMS issues guidance on hospital inpatient admission decisions

  • Case Management Weekly, Issue 5, February 2, 2011

    In order to clear up any confusion about inpatient admissions, CMS issued a special edition MLN...

Sneak peek: Pay attention to transfer DRGs and discharge status codes

  • Case Management Weekly, Issue 5, February 2, 2011

    There are specific MS-DRGs, called transfer DRGs, that can trigger certain transfer rules that...

News: Acute care hospital IPPS information available in print format

  • Case Management Weekly, Issue 4, January 26, 2011

    “Acute Care Hospital Inpatient Prospective Payment System” is now available in print...

Tip: Arrange transportation for ED patients

  • Case Management Weekly, Issue 4, January 26, 2011

    ED case manager should try, with the patient’s help, to call family, friends, or neighbors...

Your observation services questions answered

  • Case Management Monthly, Issue 1, January 1, 2011

    In a recent HCPro audio conference titled “ Observation Services v. Inpatient Admission...

Mentor moment: Communicate with coders to assign proper discharge codes

  • Case Management Weekly, Issue 51, December 22, 2010

    Proper assignment of discharge codes can make a big difference in a hospital’s reimbursement...

Mentor moment: Revenue Cycle Institute releases 2010 RAC Preparedness Benchmark Report

  • Case Management Weekly, Issue 50, December 15, 2010

    The results of HCPro’s second annual “RAC Preparedness Benchmarking Report” are...

Mentor moment: A 24-hour stay does not equal observation

  • Case Management Weekly, Issue 49, December 8, 2010

    After years of discussion and attention given to observation services and inpatient status, there...

Tip: Reviewing medical necessity of inpatient denials

  • Case Management Weekly, Issue 49, December 8, 2010

    A two-step approach may be helpful when reviewing the medical necessity of an inpatient denial.

Case Management Monthly December 2010

  • Case Management Monthly, Issue 12, December 1, 2010

    Inside: Strengthen postacute relationships to prepare for healthcare reform Handling IV...

Effective physician advisors enhance documentation

  • Case Management Monthly, Issue 12, December 1, 2010

    The rules for making proper level-of-care decisions are lengthy and confusing, which makes the role...

Properly using condition code 44 and capturing your costs

  • Case Management Monthly, Issue 12, December 1, 2010

    Condition code 44 has been problematic for hospitals since its inception in 2004 due to CMS&rsquo...

Case management team assists patient and family in obtaining benefits

  • Case Management Monthly, Issue 12, December 1, 2010

    A hospital case management team digs into a patient's past to uncover information to help create a...

Mentor moment: Medical necessity takes on new meaning

  • Case Management Weekly, Issue 48, December 1, 2010

    The concept of medical necessity takes on new meaning and significance when you consider the recent...

Sneak peek: Effective physician advisors enhance documentation

  • Case Management Weekly, Issue 48, December 1, 2010

    The rules for making proper level-of-care decisions are lengthy and confusing, which makes the role...

Mentor moment: CMS takes first step toward Medicaid RAC implementation

  • Case Management Weekly, Issue 45, November 10, 2010

    CMS released the long-anticipated proposed rule for Medicaid recovery audit contractors (RACs...

Should CMS eliminate observation services?

  • Case Management Monthly, Issue 11, November 1, 2010

    CMS has seen an increase in the number of extended observation stays and wants to know why. That...

Tip: Review one-day stays for medical necessity

  • Case Management Weekly, Issue 41, October 13, 2010

    One-day stays are common problem areas that are easy for RACs to target. Make sure your UR...

Sneak peek: Should CMS eliminate observation services?

  • Case Management Weekly, Issue 41, October 13, 2010

    Some providers think CMS can eliminate extended observation stays by eliminating observation...

Divide and conquer: Taking the UR out of case management

  • Case Management Monthly, Issue 10, October 1, 2010

    To begin to think about separating the UR function from the case management role, you must question...

Mentor moment: CMS says providers cannot use condition code 44 to backdate observation services

  • Case Management Weekly, Issue 38, September 22, 2010

    CMS issued a transmittal that explicitly states providers may not use condition code 44 to...

Mentor moment: Position your resources to prepare for RAC medical necessity audits

  • Case Management Weekly, Issue 37, September 15, 2010

    The recovery audit contractors (RAC) have certainly been busy lately. CMS gave permission to three...

Sneak peek: Dispute inappropriately denied readmissions

  • Case Management Weekly, Issue 37, September 15, 2010

    Several case managers recently have received readmission denial letters from their regions&rsquo...

Mentor moment: Providers ask CMS to abolish observation services

  • Case Management Weekly, Issue 36, September 8, 2010

    Several providers suggested CMS abolish observation services during an August 24 CMS listening...

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

  • Case Management Weekly, Issue 35, September 1, 2010

    Ongoing communication and collaboration between physicians, nurses, and case managers is essential...

Mentor moment: CMS identifies common vulnerabilities, hints at medical necessity reviews

  • Case Management Weekly, Issue 29, July 21, 2010

    CMS recently released a special edition MLN Matters article that provides information about...

Mentor moment: CMS update indicates high provider success rate for appealing denials

  • Case Management Weekly, Issue 27, July 7, 2010

    A recent CMS report indicates that providers have been winning more appeals since the last update.

Tip: Understanding reimbursement facilitates utilization management

  • Case Management Weekly, Issue 27, July 7, 2010

    Understanding how hospitals receive payment for the care provided to patients helps case managers...

Sneak peek: Case management helps with the ABN process

  • Case Management Weekly, Issue 27, July 7, 2010

    In most facilities, the patient access staff is in charge of the ABN process. However, most patient...

Prevent unnecessary readmissions: Combine revenue cycle, utilization review and quality efforts

  • Case Management Weekly, Issue 22, June 2, 2010

    During this 90-minute audio conference our speaker will discuss government regulations and guidance...

Sneak peek: Denial prevention via records and contract language

  • Case Management Weekly, Issue 22, June 2, 2010

    Documentation by the medical staff is a pillar of reimbursement success.

What does case-mix index mean to you?

  • Case Management Monthly, Issue 6, June 1, 2010

    Case managers can do their part to make sure their hospital's case-mix index is as high as possible.

News: HIPAA violator sentenced to prison

  • Case Management Weekly, Issue 18, May 5, 2010

    A former UCLA Healthcare System employee will serve four months in prison for snooping at...

Sneak peek: Patients deserve a choice in the discharge plan

  • Case Management Weekly, Issue 18, May 5, 2010

    Hospitals have options when it comes to documenting that the patient was given a choice of...

Case Management Monthly May 2010

  • Case Management Monthly, Issue 5, May 1, 2010

    Inside: The results are in: 2010 case management salary survey Identify your...

Case Management Monthly April 2010

  • Case Management Monthly, Issue 4, April 1, 2010

    Inside: ACE demonstration improves care coordination and lowers costs How can discharge...

Case Management Monthly March 2010

  • Case Management Monthly, Issue 3, March 1, 2010

    Inside: ACE demonstration improves care coordination and lowers costs How can discharge planning...

Interstate transfers create financial, logistical challenges

  • Case Management Monthly, Issue 3, March 1, 2010

    When executing an interstate transfer, case managers must account for different Medicaid programs...

News: OIG report examines RAC fraud referrals

  • Case Management Weekly, Issue 8, February 24, 2010

    Recovery Audit Contractors (RACs) referred only two cases of potential fraud to CMS during the RAC...

Sneak peek: Interstate transfers create financial, logistical challenges

  • Case Management Weekly, Issue 8, February 24, 2010

    One of the biggest challenges of executing an interstate transfer is the cost, says Matt Boettcher...

News: CMS confirms HCPro's condition code 44 guidance

  • Case Management Weekly, Issue 6, February 10, 2010

    CMS recently answered new condition code 44 questions on its FAQ Web site. The CMS answers confirm...

Sneak peek: ACE demonstration improves care coordination and lowers costs

  • Case Management Weekly, Issue 6, February 10, 2010

    Instead of paying for hospital and physician services separately, the ACE demonstration program...

Tip: Factors to consider before admitting a patient

  • Case Management Weekly, Issue 5, February 3, 2010

    Consider the following when deciding whether to admit a patient:

Case Management Monthly, February 2010

  • Case Management Monthly, Issue 2, February 1, 2010

    Inside: Your condition code 44 questions answered Milliman or InterQual: Which product is right...

Sneak peek: Milliman or InterQual: Which product is right for your facility?

  • Case Management Weekly, Issue 4, January 27, 2010

    It’s very likely that at one time or another, every person is asked one of the following...

CMW sneak peek: Your condition code 44 questions answered

  • Case Management Weekly, Issue 3, January 20, 2010

    In a recent HCPro audio conference titled “Condition Code 44 and the Utilization Review...

CMW mentor moment: ACE demonstration project could change how CMS pays hospitals and physicians

  • Case Management Weekly, Issue 2, January 13, 2010

    Essentially ACE changes how Medicare pays for healthcare services. Instead of paying the hospital...

CMW sneak peek: How can I reduce my facility’s readmission rate?

  • Case Management Weekly, Issue 2, January 13, 2010

    Medicare has not established a target date for any changes in payment methodology, but some of the...

CMW mentor moment: Length of stay should not be a secret

  • Case Management Weekly, Issue 1, January 6, 2010

    Hospital organizations need to realize and act upon the fact that discharge planning begins at the...

RAC preparedness report: Case managers are key players

  • Case Management Monthly, Issue 1, January 1, 2010

    In June 2009, HCPro launched a benchmarking survey of recovery audit contractor (RAC) preparation...

How can I reduce my facility's readmission rate?

  • Case Management Monthly, Issue 1, January 1, 2010

    June Stark, RN, BSN, MEd, lists critical interventions that help prevent readmissions and can be...

Case Management Monthly, January 2010

  • Case Management Monthly, Issue 1, January 1, 2010

    Inside: RapidView provides real-time snapshots of facility Study shows barriers to reducing...

CMW Mentor moment: RAC begins complex DRG validation audits

  • Case Management Weekly, Issue 49, December 9, 2009

    Connolly Healthcare has announced the first issues approved for complex RAC review, and providers...

Case Management Monthly, December 2009

  • Case Management Monthly, Issue 12, December 1, 2009

    Inside: Clearing up condition code 44 confusion What are some innovative ways case managers can...

CMW news: Providers report first RAC denials in Florida, South Carolina

  • Case Management Weekly, Issue 30, November 18, 2009

    Healthcare providers are starting to share their interactions with recovery audit contractors...

Case Management Monthly, November 2009

  • Case Management Monthly, Issue 11, November 1, 2009

    Inside: Clearing up condition code 44 confusion What are some innovative ways case managers can...

CMW Mentor moment: Are you paying attention to your case mix index?

  • Case Management Weekly, Issue 42, October 21, 2009

    Hospitals use the CMI to determine the budget. If the actual CMI is lower than the budgeted CMI...

Case Management Monthly, October 2009

  • Case Management Monthly, Issue 10, October 1, 2009

    Answers to your questions about dealing with undocumented patients Process tips from your peers...

CMW news: Older Americans concerned there are insufficient physicians, nurses to meet future needs

  • Case Management Weekly, Issue 37, September 16, 2009

    More than half (55%) of individuals older than 50 do not think enough physicians or nurses will be...

Case Management Monthly, September 2009

  • Case Management Monthly, Issue 9, September 1, 2009

    Inside: One facility re-develops an assessment tool to ensure documentation What are the benefits...

Free software can help you prepare for RAC audits

  • Case Management Monthly, Issue 9, September 1, 2009

    Do you ever wonder how the postacute transfer rule will affect the reimbursement for a particular...

Case Management Monthly, August 2009

  • Case Management Monthly, Issue 8, August 1, 2009

    Expediting discharges with a case manager-nurse practitioner model How CMS’ 9th Scope of...

Case Management Monthly, July 2009

  • Case Management Monthly, Issue 7, July 12, 2009

    Inside: Virtual patient advocate could reduce readmissions Case managers intervene to aid...

CMW Tip of the Week: Use a change-of-status form to ensure condition code 44 compliance

  • Case Management Weekly, Issue 27, July 8, 2009

    A change-of-status form will help ensure that a hospital meets all of the criteria for reporting...

Case managers intervene to aid admission process

  • Case Management Monthly, Issue 7, July 1, 2009

    The goal is to comply with payer rules and provide the appropriate care to patients. As simple as...

Virtual patient advocate could reduce readmissions

  • Case Management Monthly, Issue 7, July 1, 2009

    The spotlight’s shining on readmission rates. A Commonwealth Fund–supported study...

CMW News: Drug industry agrees to fund portion of Medicare doughnut hole

  • Case Management Weekly, Issue 26, July 1, 2009

    The Pharmaceutical Research and Manufacturers of America, following negotiations with lawmakers...

CMW News: Obama administration calls for more hospital payment cuts

  • Case Management Weekly, Issue 25, June 24, 2009

    In an effort to reform healthcare and reduce costs, President Obama has called for $313 billion in...

CMW news: Discuss patient financial information early in the hospital stay

  • Case Management Weekly, Issue 22, June 3, 2009

    The Patient Friendly Billing Project, a collaborative effort  spearheaded by the Healthcare...

Partner with hospitalists to improve patient care

  • Case Management Monthly, Issue 6, June 1, 2009

    Hospitalist programs are becoming increasingly popular because of their specialized knowledge of...

Observation status: Tips for accurate care determination

  • Case Management Monthly, Issue 6, June 1, 2009

    Hospitals large and small, rural and urban, face a common struggle to ensure that their patients...

Case Management Monthly, June 2009

  • Case Management Monthly, Issue 6, June 1, 2009

    Inside: Observation status: Tips for accurate care determination Partner with hospitalists to...

CMW News: Housing and care coordination reduce hospitalizations

  • Case Management Weekly, Issue 19, May 13, 2009

    Offering case management intervention and housing to homeless patients reduced hospitalizations by...

The RAC is back! How can I prepare my facility?

  • Case Management Monthly, Issue 5, May 1, 2009

    The time is now for RAC readiness for case management departments throughout the country.

Case Management Monthly, May 2009

  • Case Management Monthly, Issue 5, May 1, 2009

    Case Management Monthly, an 8-page monthly newsletter, is a one-of-a-kind training, support, and...

CMW News: ED visits and costs rise in Massachusetts

  • Case Management Weekly, Issue 17, April 29, 2009

    Despite Massachusetts’ mandated health insurance law that became effective in 2006, ED visits...

CMW Tip of the Week: Discounts to uninsured or underinsured patients

  • Case Management Weekly, Issue 14, April 8, 2009

    Hospitals may discount services to uninsured and underinsured patients who are unable to pay their...

Changing times call for weekend case management coverage

  • Case Management Monthly, Issue 4, April 1, 2009

    Adding weekend case management at your facility may seem like a difficult task or an unnecessary...

CMW News: One-third of patient bad debt should be classified as charity

  • Case Management Weekly, Issue 13, April 1, 2009

    A study of 148 hospitals in 2008 has identified that nearly 31% of patient revenue written off as...

CMW News: Communities cut care for undocumented immigrants

  • Case Management Weekly, Issue 12, March 25, 2009

    Many healthcare providers believe it would be better practice to spend $100 providing primary care...

CMW News: Iowa hospitals struggle in hard economic times

  • Case Management Weekly, Issue 11, March 18, 2009

    The Iowa Hospital Association (IHA) reports declines in service areas and increases in charity care...

CMW Tip of the Week: Who should receive RAC correspondence?

  • Case Management Weekly, Issue 11, March 18, 2009

    This week’s tip, an “Ask the Expert,” comes from Karen Feeley, director of...

MedPac recommends increase in 2010 hospital payments

  • Case Management Weekly, Issue 9, March 4, 2009

    The Medicare Payment Advisory Commission (MedPac) recently provided Congress with its...

CMW News: Keeping aging patients out of the hospital is harder than it seems

  • Case Management Weekly, Issue 7, February 18, 2009

    A recent study aimed at keeping elderly patients with chronic conditions out of the hospital...

CMW Tip of the Week: Address one-day stays before the RAC permanent program begins

  • Case Management Weekly, Issue 7, February 18, 2009

    It is no secret that RACs focused on one-day stays in the demonstration project. So what are you...

CMW News: The RAC is back on track

  • Case Management Weekly, Issue 6, February 11, 2009

    The Centers for Medicare & Medicaid Services announced on February 6 that the contract protests...

CMW News: Hospitals facing extreme funding problems

  • Case Management Weekly, Issue 4, January 28, 2009

    Nine out of 10 hospitals reported that borrowing money has become harder due to the economic...

CMW News: CMS announces demonstration sites for bundled fee-for-service payments

  • Case Management Weekly, Issue 2, January 14, 2009

    In an effort to better align the incentives for both hospitals and physicians, CMS has established...

CMW News: California bans "balance billing"

  • Case Management Weekly, Issue 2, January 14, 2009

    The California Supreme Court recently ruled that physicians can no longer bill patients for...

Improve patient advocacy by creating a managed care partnership

  • Case Management Monthly, Issue 1, January 1, 2009

    Managed care companies are viewed as the Goliath to a case management program’s David...

CMW News: Hospitals receive different reimbursements for identical procedures

  • Case Management Weekly, Issue 47, November 26, 2008

    Some Massachusetts hospitals earn much higher rates than other hospitals in the state for...

CMW Tip of the week: Understand the difference between a Medicare appeal and a Medicare reopening

  • Case Management Weekly, Issue 46, November 19, 2008

    This week’s tip is provided by Deborah K. Hale, CCS.

CMW News: Hospitals see decline in paying patients, rise in non-paying

  • Case Management Weekly, Issue 46, November 12, 2008

    As emergency departments are filled to capacity with patients who have no insurance or can’t...

CMW News: Palliative care programs save hospitals money

  • Case Management Weekly, Issue 45, November 5, 2008

    While palliative care is a relatively new specialty, a recent study provides more evidence of its...

CMW News: Health insurance companies urge physicians to prescribe generic drugs

  • Case Management Weekly, Issue 45, November 5, 2008

    In the past, drug companies have been criticized for encouraging physicians to prescribe their...

Manage your fear of the RAC

  • Case Management Monthly, Issue 11, November 1, 2008

    CMS’ Recovery Audit Contractor (RAC) program elicits feelings of fear, but Brenda Keeling...

LOS initiative saves one facility more than $1 million

  • Case Management Monthly, Issue 10, October 1, 2008

    When New Hanover Regional Medical Center (NHRMC) in Wilmington, NC, wanted to decrease LOS...

Collaboration accelerates discharge planning process

  • Case Management Monthly, Issue 10, October 1, 2008

    St. Luke’s Episcopal Hospital in Houston had several problems in its ICU: LOS rates had...