The Role of the Hospital Case Manager in Clinical Denials and Appeals

In the past, the focus on denials and appeals to denials was primarily a part of post-discharge and was performed by the hospital finance department. This resulted in a siloed approach to clinical denials and appeals. Additionally, some hospitals farmed out CMS denials to the Compliance Department, even resulting in a more siloed approach. This resulted in minimal collaboration among all of the staff involved in reimbursement and compliance for reimbursement. The Case Management Department rarely understood denials related to them—both clinical and administrative), and as a result, there have been few strategies allotted to the clinical denial process.

As reimbursement has become driven more by medical necessity criteria and quality outcomes, case management has become an integral part of the revenue cycle. RN case managers, social workers, and case management leaders are all key stakeholders in the hospital’s revenue cycle.

To ensure effective denial and appeal management, it is imperative that the case management team understand the denial and appeal process and understand their role in positively and negatively impacting it. This collaboration requires strategic roles and partnerships between and among all revenue cycle stakeholders, including physicians, case management staff, ancillary staff, and nursing. Others Involved in an effective denial and appeal process include the physician advisor, utilization review specialists (if UR is separated from the RN case manager function), and the managed care contracting staff.

CMS is implementing programs that support paying not only for volume but also for value. In fact, it is moving toward a majority of payments to hospitals being for value, rather than for volume. With mandatory and voluntary bundled payments, case management staff need to be actively involved, if not leading, denial, and appeal management initiatives.

This webinar by Bev Cunningham, MS, RN, ACM will focus on understanding the process for denials and appeals, barriers in the patient care process that can set the scene for potential denials, managed care contract content relating to denials and appeals, and processes that must be in place to ensure case management is at best practice in each of their roles. This session will include information for both staff case managers and social workers and case management leadership.

Bev will provide resources and the Denial management dashboard along with the final presentation deck.

Webinar Objectives

Denial management is often siloed in hospitals. This session will discuss the collaborative role of key stakeholders in effective clinical denial and appeal management.

Often time RN case managers and social work case managers do not understand the denial and appeal process. There may not be an expert in the department, such as an appeal coordinator. This session will education case managers in their role and will also discuss the role of the appeal coordinator.

Not often is there an effective dashboard for the department and the Utilization Management Committee to review to understand the denials and appeals that occur. Likewise, staff members are not aware of their impact on denials. This session will address a possible dashboard to use that can set the scene for best practice denial management.

Webinar Agenda

• Hospital case management roles related to denials and appeals
• Denial definition
• Types of denials
• Compliance issues related to denials
• Impact of stakeholders on case management
• Role of the physician advisor in denials and appeals
• Role of the RN case manager in denials and appeals
• Role of the social worker in denials and appeals
• Role of the case management leadership team in denials and appeals
• Appeals coordinator
• Role of the UM Committee in denials and appeals
• Payer contract management related to clinical denials and appeals
• Denial management dashboard

Webinar Highlights

Who Should Attend

• Hospital Director of Case Management
• RN Case Manager
• Utilization Review RN Specialist
• Appeals Coordinator
• Physician Advisor
• Hospital executives responsible for case management
• Chief Medical Officer