Using case management to improve claims payment - patient account management

Healthcare Financial Management, May, 1995 by Julie A. Micheletti, Steve Mevert, Thomas J. Shlala

With a case management program, providers can assemble data that specify documentation each payer requires. This procedure not only will increase the chance that a claim will contain all the information needed to expedite payment; it also will reduce the chance of introducing errors in claims by submitting more information than is required.

Seek pre-authorization from payers for cases that are expected to incur high costs. Case management will identify the threshold dollar amounts of claims that automatically trigger review by individual payers. When a case manager expects treatment of a particular patient to exceed the threshold for a payer, he or she may contact the payer before treatment begins to arrange terms of payment.

For example, a case manager may arrange to bill separately for individual treatment services at designated intervals, negotiate a higher than usual discount, seek authorization for continued service based on the patient's progress every seven days, or specify that the payer must provide 14 days notice to allow for discharge planning if the payer is not willing to pay for a costly course of treatment.

Conclusion

Provider case management creates effective, interactive communication between the claims office and the clinical services area. This communication will improve payment because it will help providers respond to the techniques used by payers to control reimbursement.

a. Falik, Marilyn, et al., "Case Management for Special Populations," Journal of Case Management, 2 (2), Summer 1993, p. 41.

b. Grimaldi, P., Micheletti, J., and Shlala, T., "New Home Health Quality Standards Will Trigger Operational Changes," Healthcare Financial Management, December 1989, p. 48.

About the authors

Julie A. Micheletti, RN, is vice president of clinical systems, Healthcare Design Systems, Sea Girt, New Jersey.

Steve Mevert, RN, is administrator, Miller Project Hospice Program, Fresno, California.

Thomas J. Shlala, RN, is director of nursing, Vale Care Center, San Pablo, California.