Partnering with payer case managers/utilization nurses

Case managers must begin to learn the skill of brokering for care. The goal of private payers is to provide the most cost-effective care that meets medical necessity for services and increases likelihood for recovery. With that said, many plans do not or will not include the various levels of care that patients need.

For example, consider a patient who had a stroke but whose benefit covers only skilled nursing facilities (SNF), not acute rehabilitation services. The difference between the levels of care can be dramatic in that SNFs can only guarantee one hour of therapy and one therapeutic approach, whereas acute rehabilitation facilities offer at least three hours of therapy per day and at least two modalitiesof therapy. Clearly, a stroke patient who goes to a SNF first rather than directly to the correct level of care (acute rehabilitation) will take longer to recover and use more of the healthcare system. This could mean more dollars spent on acute hospitalization and a failed recovery plan leading to emergency department visits and readmissions. A resourceful case manager will provide a cost-benefit analysis to negotiate the best type of care for the patient.
 

Case managers must understand the implications of the patient’s plan across the care continuum, be aware of the cost of care, and advocate for the patient to have the best possible plan.

For more information, see Longitudinal Case Management: Designs Across the Continuum of Care.

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