While supplies last! Free 2022 Coding Essentials for Infusion & Injection Therapy Services book with every RACmonitor webcast order. No code required. Order now >

Whether you call it care management, case management or utilization management, the idea is the same: a hospital department that proactively ensures appropriate utilization of resources to prevent losses and waste. This requires a systematic approach across the whole organization, and a good system must be made up of good structures, processes and people.

The structure of care management dictates how the department is organized in terms of reporting, roles and communication. The processes include policies, procedures, job descriptions, and methods of accountability. The people include qualified individuals who have the skills listed in the job descriptions, and those able to offer the appropriate and regular training of those individuals to execute all aspects of the job.

For this article, I will focus more on processes, with a short word about structure and people. Because of the central role care management plays in all hospitals, I recommend that the department report to the highest level possible in the organization (with, in many cases, selection of the CFO as the executive responsible for overseeing it). As far as people go, issues we often see include lack of accountability, failure to collect and assess data (i.e. using scorecards) and an absence of consistent and ongoing training to keep staff updated on the latest regulatory requirements.

While hospitals may take different approaches to care management, there are certain core processes that must be in place to protect your hospital from being out of compliance with conditions of participation (CoPs) and thereby subject to high levels of billing denials.

First, every observation patient and inpatient must be screened to ensure that they meet medical necessity criteria; second, patient documentation should receive concurrent review to determine medical necessity of continued stay; and third, each patient must be assessed early in his or her stay for discharge planning needs.

To facilitate and manage these reviews, care managers must be deployed in such a manner that each entry point into a hospital bed (inpatient and observation) triggers scrutiny of the admission order, with an eye on medical necessity appropriateness and compliance. This includes patients undergoing procedures such as cardiac catheterization or other procedures that may have started as outpatient but are converted to either inpatient or observation status.

Every hospital should educate key stakeholders (such as care management, nursing and physician staff) on how patients enter the hospital in order to plan staffing and resource allocation to match the demands of medical necessity review. With the intense care management required in our heavily regulated environment, we recommend a 20-to-1 patient-to-care manager ratio (or a lower figure, if warranted).

When hospitals review their care management structure and processes, they often find that the true “front door” is the emergency department (ED); some hospitals report up to 80 percent of patients coming through the ED, in fact. Depending on the size of your facility, you may divide care management roles into admission care managers and continued-stay care managers. Whether or not you separate the roles, it still may be prudent to assign a compliment of admission care managers to your ED to work closely with the ED physicians, hospitalists and attending physicians on bed status prior to physician orders being written.

By working side-by-side with the ED staff and physicians, a care manager is able to interact with patients and have access to the most current patient information and diagnosis reports, allowing the care manager to advise physicians on appropriate status. The care manager also may assist in liaising with family and community resources as it pertains to alternative placement. The benefit involves identifying those patients who do not meet criteria for either inpatient of observation status. A care manager or social worker also can develop a discharge plan directly from the ED to community resources, preventing unnecessary acute-care stays.

Admission care managers cover other entry points into the facility based on patient volumes. All of this requires understanding and cooperation among other clinical departments and medical staff. For instance, the department responsible for accepting direct admissions or calling for a bed from a procedural area also should have a tandem system to notify the care management department for medical necessity review.

For most hospitals, it is impractical to staff care management 24 hours a day, seven days a week. A viable alternative is outsourced first-level review performed during those times when your own staff is not available. This may include nights and weekends (although we recommend some level of care management staffing on the weekend) when no care management staff is on site, or it also may be during times of high patient volume. The key is to get to the review quickly, at least within 12 hours of admission. If a third-party resource is used for nights and/or weekends, it is often appropriate to have the on-site care manager initiate a concurrent review or additional admission review upon arrival the next business morning.

The admission medical necessity review is likely to be accepted by the medical staff once a good review system is in place; however, every care manager should have a trained physician advisory (PA) available for second-level review. The PA specifically should be trained in regulatory requirements and documentation for medical necessity and complaint billing. After a care manager applies criteria and advises a physician on bed status, there still may be disagreement between the admitting physician and the care manager. In these cases, escalation to a PA is appropriate. While the care manager is utilizing a certain set of criteria, the PA will go beyond that set of criteria to apply medical judgment. Typically, the PA will call and discuss the admission and bed status with the admitting physician. In order to ensure availability of a PA at all times, facilities may choose to have additional PA coverage from an off-site third party.

Recently we have seen PAs becoming even more involved, up to and including making rounds with hospitalists to educate and ensure appropriateness of admission or continued stays.


This brings us to our second function: concurrent review for continued stay. Because of the need to move patients appropriately through each stay, most patients should receive a daily review for continued medical necessity. This can be accomplished simply by having unit-based care managers who can develop relationships with nursing staff, other clinicians and physicians. A five- to 15-minute unit “huddle” led by a care manager and including pharmacists, nurses and physicians to review patients every morning will catch issues related to medical necessity, discharge, or change in condition.

For observation patients, nursing and care managers should review their cases more than once a day to determine whether the patients should go to a different level of care, or perhaps be converted to inpatients. Patients with a long length of stay may warrant a separate outlier review by the care manager and PA, a process that can involve the assembly of an appropriate care team and leverage of the proper resources to ensure that such patients have effective discharge plans.

As mentioned above, discharge planning is the third key function of care management. As a Centers for Medicare & Medicaid Services (CMS) CoP, it is essential that hospitals have a system for assessing and planning discharges at the front end of each stay (i.e. upon admission). Even as we see shortened lengths of stays and more inappropriate use of the ED, we do not always see hospitals start discharge screening and planning in the ED or upon admission. As part of the initial patient assessment, a nurse or care manager should conduct a screening for high risk. The assessment should trigger further evaluation and action by care management if the patient is expected to have anything other than a routine discharge. Through care management, along with the other caregivers and physicians, developing a safe discharge plan early may help avoid delayed discharges and readmissions. There are many assessment tools available online.

To many reading this article, this may seem like old news, but in reality, many hospitals have not moved the utilization review function to the very start of patient care, creating the consequence of reducing compliance and increasing denials for payment. Take time to review your systems, and improve them if warranted.

You’ll be happy you did.

About the Author

Elizabeth Lambin, MHA, is a partner in PACE Healthcare Consulting. Elizabeth has more than 20 years of C-suite level hospital executive management experience.  Most recently, she was the CEO/Market President for Tenet Healthcare’s Hilton Head Regional Healthcare. Elizabeth holds an undergraduate degree in Business Administration, Cum Laude and a Master’s in Healthcare Administration from the University of South Carolina.

Contact the Author


To comment on this article please go to editor@racmonitor.com


You May Also Like

Leave a Reply

Your Name(Required)
Your Email(Required)