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Where does case management fit in the revenue cycle?

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The role for case management can be defined in terms of its area of expertise, which includes utilization review (UR), discharge planning, regulatory compliance related to reimbursement, and the use of those regulations to safeguard against unnecessary admission of patients.  Through the advance beneficiary notice (ABN), hospital issued notice of noncoverage (HINN), and the important message from Medicare (IM) process case managers provide a critical oversight to appropriateness of care.  Case management also has a role in the appeals of denials and the tracking and trending of denials that lead to process improvement. Revenue cycle meetings discuss areas in which the hospital cannot collect or bill appropriately for services that have been rendered.

Traditional revenue cycle management includes the expenditure of efforts and resources on the back end prior to the bill being dropped. Because case managers can prevent denials and are positioned to report on status issues, they can positively affect the ability to improve processes that lead to greater revenue capture in a timely manner. Laforge and Tureaud stated the following in Financial Management, which describes the need to use a proactive approach within the revenue cycle:

“The revenue cycle correlates strongly with the patient-flow process, which runs from scheduling and registration through treatment, discharge, and collection. In the past, hospitals tended to focus their efforts at the end of this process, on billing and collection. Yet most revenue-cycle problems originate early on, at the time when the hospital is collecting and verifying patient information needed to ensure submission of a clean claim and receipt of full payment. Rather than address problems retrospectively, hospitals should focus their efforts on front-end processes that help ensure the problems do not arise in the first place (Laforge, Tureaud 2003).

-Paul Arias, RN, BSN, MIS