What Does Your Case Manager Offer?

Case management is a nursing assessment --an analysis of the facts gathered.  It is not a reiteration of the facts, but is an evaluation or “nursing opinion” of the facts and what they mean in terms of the injured worker’s medical/disability status.

Submitting Medical bills into Evidence—Illinois Collateral Source Rule

To submit medical bills into evidence at trial in Illinois it is typically required to show that the medical services provided and charges incurred were usual, customary, and reasonable.  To demonstrate the reasonableness of the provided services and the charges of those services it is often necessary to introduce the testimony of a person with knowledge  of both the medical necessity of the services rendered and the understanding of  usual  and customary charges for those services.

Many times the medical appropriateness of the services provided is introduced by the medical providers themselves or by providers within the same discipline.  These individuals are not always the best choice to demonstrate the appropriateness of the billed charges.

This analysis necessitates understanding the environment of the services rendered, in addition to healthcare reimbursement practices and methodologies

Complex System

The healthcare reimbursement system is complex with multiple layers culminating in both the billed price and the price that is ultimately reimbursed.  The process varies with each place of service.  A thorough understanding of the ICD (diagnosis medical record or the medical bills is fraught with a number of hurdles.  A HIPPA compliant release of information is the first tool.  The next step is identifying the individual within the facility or provider’s office that has the authority to release the record and the bills.  Within many facilities and large offices these are two different individuals.  A few well-placed calls to the provider will disclose the contact name and number and the process for requesting the information.  

As previously mentioned providers periodically change billing systems and methods.  You will be told the UB no longer is available.  To avoid this inevitable response it is prudent to request the medical bills periodically throughout a long treatment cycle or as soon as possible at the end of treatment.  A gentle reminder that UB must be supplied to the insurance carrier or the workers compensation provider to obtain payment for services may help to overcome a reluctant participant.  It may not hurt to remind them that HIPPA states the patient is entitled to obtain their entire PHI (protected health information). Ultimately, a subpoena may need to be issued to obtain the completed medical and billing records.  With proactive preparation and a qualified medical bill reviewer your bills will find their way to trial.

                                                                      Preparation… 

When enlisting the assistance of an individual to attest to the usual, customary and reasonableness of the medical bills the following documents should be obtained from the providers:

• CMS-1500 claim form for all professional bills (sometimes referred to a HCFA - the previous name for the CMS-1500 claim form)
• UB claim for all facility claims (UB92 or UB04 are acceptable)
• A dental Claim form from all dental providers
• Obtain an itemized statement from any ancillary service (durable medical equipment, pharmacy, transportation service, or medical supply company)
• Inform the provider that you are seeking all the procedure codes associated with the services rendered

Next…

It is necessity to obtain all corresponding medical records if it is determined that the person who will testify to the reasonableness of the bills will also be the individual responsible to attest to the appropriateness of the services provided. The medical reviewer will then be able to identify if the services provided are related to the injury of record, are appropriate to care for the diagnosis/ diagnoses, are medically necessary, and are actually documented as provided. 

Hurdles and Hope

The process of obtaining the necessary information for the medical reviewer to adequately assess the medical record or the medical bills is fraught with a number of hurdles.  A HIPPA compliant release of information is the first tool.  The next step is identifying the individual within the facility or provider’s office that has the authority to release the record and the bills.  Within many facilities and large offices these are two different individuals.  A few well-placed calls to the provider will disclose the contact name and number and the process for requesting the information.  

As previously mentioned providers periodically change billing systems and methods.  You will be told the UB no longer is available.  To avoid this inevitable response it is prudent to request the medical bills periodically throughout a long treatment cycle or as soon as possible at the end of treatment.  A gentle reminder that UB must be supplied to the insurance carrier or the workers compensation provider to obtain payment for services may help to overcome a reluctant participant.  It may not hurt to remind them that HIPPA states the patient is entitled to obtain their entire PHI (protected health information). Ultimately, a subpoena may need to be issued to obtain the completed medical and billing records.  With proactive preparation and a qualified medical bill reviewer your bills will find their way to trial.   By Barbara King, BSRN, QMRP, CPC, MSCC

ALERT-Aggressive Case Management

ALERT is an acronym which describes the process of aggressive case management.  It is not additional information that is required to be documented in the case.  This process should be completed on every verbal encounter to ensure consistent, high quality customer service. 

ALERT ensures aggressive return to work and promotion of an active treatment plan.  The nurse’s recommendations establish an appropriate plan of action and proactive recommendations.  The file is managed by utilizing established criteria, goal setting and timely communication.

First the nurse assesses the return to work plan and treatment plan by asking the following questions:

•   Did I compare the treatment plan with criteria?
•   Do subjective and objective findings match the diagnosis given?
•   Do subjective and objective findings gel with the treatment plan proposed?
•   Did I question, probe, and challenge the treatment plan?
•   Did I compare the work status with criteria?
•   Do the subject and objective findings match the return to work status/recommendations?
•   If totally disabled, why?  Is it appropriate?
•   If partially disabled, why?  Is it appropriate?
•  What are the injured worker’s capabilities?
•  What can she/he do?
•  Have I discussed light, modified duty?

The case manager then formulates a clear direction.   She maintains control of the case while giving the account assistance in making his/her claim decision.  The emphasis is the “big picture” and not just one episode of care.

The case manager formulates her plan of action by asking herself the following questions:

•   Was I aggressive in obtaining information so that I can move forward?
•   What steps do I plan to take to stay in control?
•   How do I keep my recommendations alive and achieve my case goals?

The case manager then turns her attention to comparing the treatment plan against the criteria for the injured worker’s diagnosis.  She addresses the following:

•   Have I determined within optimal criteria when this injured worker should be expected to return to work?
• Have I determined within optimal criteria when this injured worker should be expected to reach maximum medial improvement?
•  Did I update the return to work and maximum medical improvement estimates when the time frames were exceeded?
• Did I establish my own goals for return to work and maximum medical improvement when no criteria information is available?
•  Did I consult a resource to establish a goal if there was no criteria available and I was unable to establish a goal?

The next step is to review the expectations and service request from the account. 

• Does my referral source have an agenda that is somehow different from my own?
• Have I communicated any red flags that I might have encountered?
• Have I communicated in a way that is beneficial to my referral source?

The last step in the process is communication to provide all parties with the rationale for the medical information supplied so that they have a clear understanding from a medical standpoint.  All parties will understand why the recommendations are what they are and why the treatment plan is appropriate.  The case manager gives the account the rationale for the disability status.  Stating that “the injured worker is disabled and I will follow-up “, is not sufficient.  

In summary, case management is not a passive information collecting process.  The nurse case manager is an active participant utilizing the nursing process of assessment, diagnosis, outcome planning, implementation and evaluation.