Sixty-five percent of hospitals have a case management program in their emergency departments, and of that percentage, nearly a quarter run their programs 24/7, according to a recent Change Healthcare survey.
What's more telling is that of those hospitals running 24/7 programs, 87 percent of respondents said they could prove the value of their case management program, according to Diana Cokingtin, MD, medical director of decision support at Change Healthcare. Dr. Cokingtin, who has two-plus decades of experience in managed care with companies like Blue Cross and Blue Shield of Kansas City, Molina Healthcare, Coventry Health Care and Aetna, spoke with attendees about case management on May 10 at Becker's Hospital Review's Health IT + Revenue Cycle 2018 conference in Chicago.
Here are two standout quotes from Dr. Cokingtin's presentation.
On the importance of documentation. "In the world of managed care, if it's not written in the records, it ain't done. So if you don't document properly, the managed care companies in a retrospective review aren't going to be able to find out how they fill that patient therapy. They're not going to know the patient went to the doctor three days ago, got a prescription, filled that prescription, took it as prescribed and now they came in even sicker than they were. So by having your care management [in the ED], working with whoever is writing the admission orders as well as writing their initial HMP, they can remind them of those things. It's very important your documentation be good, and ultimately it will help you reduce denials if you have better documentation as well as not admitting patients who don't need to be in the hospital to begin with."
On leveraging payers as resources. "You might find this hard to believe, but payers don't come to work and say, 'I'm going to deny 15 cases to this hospital and 10 at this hospital.' That's not what they do in the mornings. They're going to come in and they're going to work with their nurses as well. They're going to go over those cases. … If you have patients who repeatedly come to your ER and repeatedly get admitted and sometimes are the reasons you get denials from insurance companies, figure out who your frequent flyers are. Take that list and see if any of them have insurance companies. And if they do, do you have a relationship with the case management unit at that insurance company? Because then you ask, 'Can we be part of your care team for this patient?' You're part of the equation. Then you're leveraging their resources, you're not spending your resources on managing this patient."