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.
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 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 March, President Obama signed the Patient Protection and Affordable Care Act into law. Although the regulations enacting the legislation remain on CMS’ to-do list, providers expect changes to how the government pays them.
Unlike politicians who only give lip service to working with rivals, BryanLGH and Saint Elizabeth Regional Medical Center have joined forces to create Lincoln ED Connections, which helps patients who use the ED for primary care.
Physicians can defer admission decisions to those who truly understand level of care—the case managers. The method is called the “admit per case management protocol.
