Case Management

Tip: Understanding reimbursement facilitates utilization management

Case Management Weekly, July 7, 2010

Understanding how hospitals receive payment for the care provided to patients helps case managers perform the utilization management function with minimal effort.

Case managers should realize that every hospital has multiple payers. Several factors contribute to this variety of payers. One example is geographic area (e.g., rural or urban). Other potential factors include the population of the hospital’s primary service area, patients seen by high-volume admitting physicians, and patients in a particular service line such as cardiology, obstetrics, or oncology.

Case managers also should know that a hospital unit may have a differing mixt of payers based on its patient population. For example, a medical unit may have primarily Medicare patients, whereas a pediatric unit may have a mix of Medicaid and managed care patients. Being aware of payer mix in an assigned unit is essential for understanding the utilization management process.

This week’s tip is adapted from Core Skills for Hospital Case Managers: A Training Toolkit for Effective Outcomes published by HCPro, Inc. For more information about this book or to order your copy, visit the HCMarketplace.

Do you have a question about a case management topic? Send it to Associate Editor Ben Amirault at An answer to your question might appear in a future issue of Case Management Weekly.

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