Effective Case Management Leadership: Helping Organizations Meet Value Based Care and Denial Management Challenges

In this post, we will share the experiences Revint Consulting has had with healthcare clients needing support with Case Management to meet denial management challenges. Case Management departments report to a myriad senior leaders including Chief Financial Officers, Chief Nursing Officers, Chief Medical Officers, and Chief Quality Officers. Much of what we find is leaders who receive responsibility for Case Management and have been successful in achieving results while managing complex processes requiring attention to details. However, in the Case Management arena, our clients have told us “we don’t know what we don’t know” and the impact on the financial results on the organization can be unexpected. Often this lack of awareness results in government repayments (from value-based care), financial penalties (from Hospital Readmission Reduction Program), and revenue not captured due to failing documentation processes. Those process issues frequently occur between physicians, case management, health information management, coding, information technology, and clinical documentation.

Background

Case Management programs with ineffective processes are found to negatively impact the financial performance of many health care organizations. This often occurs when the following issues are identified by hospitals and/or health care systems (and has been the case with some of our clients):

• Is changing the care delivery model from fee-for-service to value based care
• Inpatient length of stay (LOS) is high with a LOS Index greater than 1.5 across multiple Diagnosis Related Groups (DRGs)
• Observation patients are staying greater than 2 midnights
• Patient status on entry into the hospital is incorrect and not followed during the patient LOS resulting in an underpayment and/or denial of payment
• Medical necessity denials are high
• ED or hospital readmission rates are higher than expected with financial penalties associated with the Center for Medicare and Medicaid Services (CMS) Hospital Readmission Reduction Program (HRRP)
• Hospital Boards are requiring immediate remediation of high LOS, readmission rates, and correction of causes of denial of payments
• Difficulty in negotiating rates and contracts with third party payors

The Case Management department has experienced frequent leadership turnover or has ineffective leadership resulting in:

• Job duties are not clearly defined, resulting in duplication or omission of duties
• A staffing plan is not defined or appropriately implemented
• Staff accountable for utilization review and case management do not work hours necessary to cover the organization management of patients
• There is no written education plan or dedicated education leader within the Case Management department
• New admissions are not screened and stratified for readmission and post discharge placement risk (i.e. low, moderate, high)
• Interdisciplinary care coordination, communication, rounds, patient flow, and collaboration needs improvement

Case Management Challenges

Revint provides our clients with Case Management department level leadership and organizational need assessments of their Case Management departments to effectively understand the current gaps in processes. Many organizations lack internal knowledge of Case Management functions, work flows, and tracking of data to support organizational goal setting and tracking. Interdisciplinary relationship development is often misunderstood related to how one discipline impacts the outcomes in another discipline. These relationships ultimately impact the financial health of the organization related to LOS, readmission penalties, denial of payments, case-mix, patient throughput, all of which have long-term financial effect on the organization. Due to silos and an unawareness of the impact, oftentimes organizations are either unclear of the effect of the silos; or if aware, are unsure of how to re-design a model that corrects and produces the interdisciplinary team with shared goals for organizational financial improvement.

Case Management Insights

Revint clients have received support with Case Management assessments, implementation of needed changes, and Director level support.  By placing our Case Management leadership, our clients have realized support and improvements. Some of the results we have helped organizations achieve include:

• Thorough assessments and gap analyses of Case Management functions within the organization including department level, Information Technology usage, Billing and Coding departmental functions, Physician roles, Revenue Cycle processes, and provide the organization with an implementation plan
• Job descriptions for Case Managers, Social Workers, Clinical Documentation Improvement Specialist, and other team members
• Mentorship of current Directors of Case Management to support program development and program tools to assist with long term changes
• Implementation of Pre-Access call centers to support correct status prior to hospital entry thereby improving the billing process and reduction in denials
• LOS management with reduction achieved greater than 1.0 days typically within 30 days
• Comprehensive assessment tools for the Emergency Department, Acute Care, and Post-Acute Transitions of Care
• Education Plans for new hires and program re-design for staff and physicians
• Support tools for medical staff to improve understanding and compliance with thorough and accurate documentation
• Management of data for outcomes tracking including LOS, denials, CMI, and revenue recovery
• Work flows and standard work tools to track compliance with implementation re-design

Summary

Efficient and effective Case Management programs produce positive financial and patient-centered outcomes. Through the implementation of an integrated model, organizations can achieve improved LOS management, and tackle denial management challenges through improved documentation of medical necessity, while preparing for Transition of Care programs to reduce readmission rates and penalties.