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Every hospital-based case manager knows how difficult it can be to establish effective working relationships with case managers from insurance companies. Too often, conflicts over length of stay, reimbursement, and other issues lead to adversarial, even hostile, working relationships where everyone loses, including the patient.
B.K. Kizziar, RNC, CCM, CLCPM, president of BK & Associates in Dallas, says one way to improve these relationships is for each side to treat the other as a customer. "It almost comes down to a customer service issue," says Kizziar, who also is president of the Dallas/Fort Worth chapter of the Case Manager Society of America. "Both of them are each other’s customers, and we have to be prepared to provide the best customer service."
It’s critical to create opportunities to generate information about appropriate methods of communication and information in order for each side to do its job and facilitate the hospitalization and discharge of the patient, she says.
That is no easy task, however. "Sometimes, it is almost like navigating between two different languages," says Debra Payne, RN, CCM, director of case management at LifeCare Hospital in Fort Worth, TX. "Not everybody understands the dynamics on both sides of the fence, and that creates a natural opportunity for miscommunication."
Not only is there no standard protocol for how these two sides deal with each other, sometimes, there are disparities within the same organization. "It varies from hospital to hospital, explains Payne. "There are no guidelines, and there are no governing bodies in this area," she says.
Unfortunately, it’s often the patient who is subject to the consequences of inadequate communications, warns Kizziar. And too often, hospital and managed care case managers appear to be at odds with one another, she says. "It can appear as if the hospital wants to keep them, and the insurance company wants to get them out."
While that tension often is unavoidable, it can be mitigated, according to Kizziar. First, both sides must create opportunities to candidly discuss the needs of the patient and what the discharge needs are going to be. If both sides also address how long it will take to meet those needs and how to move forward, that almost always allows for a smoother discharge as well as improved continuity in the type of care patients receive, she says.
One of the biggest stumbling blocks emerges when the hospital case manager does not have sufficient information about the clinical status of the client, Kizziar says. That prohibits the external case manager from approving additional days and making recommendations for appropriate contracting. "Sometimes discharges are hastily done because of that lack of communication," she explains.
When the hospital case manager has appropriate information about the clinical status of the client, the plan of care, and what will be required at discharge, the external case manager will have the facts he or she needs to approve an appropriate length of stay as well as additional services beyond the inpatient stay.
That is important for several reasons, says Payne, who also has experience dealing with this issue from the payer perspective. "We are trying to cultivate that business." In fact, Payne says that when LifeCare designed its program, decision makers spent time brainstorming about the needs of external case managers and how to be more customer-friendly.
Payers are facing a very competitive environment, notes Payne. "For our level of care, there may be several hospitals they have a contract with, which means that it is up to the family and the payer and the patient to determine which facility is selected," she explains. Sometimes, that process is driven by the patient. Other times, however, the patient might not have any input, and it is more physician-driven, she adds. "Sometimes the steerage comes from the insurance company, and that is what we try to capture. We want them steering patients our way."
Payne says that is especially important for LifeCare because it is a specialty acute care hospital. Unlike traditional short-term hospitals, LifeCare is DRG-exempt and is not reimbursed for its Medicare patients the way traditional short-term hospitals are.
"We are cost-based reimbursed, which means that we basically don’t make any money on Medicare patients," explains Payne. That creates some challenges and unique perspectives with respect to external case managers. "It creates an opportunity to have a patient that might add a little marginal revenue," she explains.