Rita, an 82-year-old female, is involved in a motor vehicle accident while traveling from South Dakota to Arkansas in early January. She arrives at the hospital Sunday afternoon with a concussion and two fractured ribs.
The appeal process is much more complex than conducting a clinical review for an insurance company. Appeal writers must complete a full review of the record and consider multiple sources, such as CMS guidelines and managed care contracts, to successfully argue their case.
In an environment of limited resources, ensuring care for patients post-discharge can challenge any case manager’s creativity. Rural locations in particular can pose problems related to serviceable areas and resource availability.
The American Case Management Association (ACMA) Public Policy Committee is in communication with CMS to change the requirements for the second Important Message from Medicare (IM).
