Case Management's Role in Managing and Preventing Third Party Payer Denials
Instructor:
Toni Cesta
Product ID: 705584
- Duration: 60 Min
Why Should You Attend:
Case management, as a member of the revenue cycle team, plays a strategic role in the implementation of strategies aimed at reducing and/or preventing third party payer denials. Reducing and preventing denials requires proactive and hard-wired processes that engage the entire interdisciplinary care team. The causes of denials are complex and therefore require complex solutions.
This program will review the causes of denials and key strategies for reducing and preventing them. Solutions will include key members of the interdisciplinary care team including physicians, physician advisors, case management leaders and case managers. Strategies for analyzing your denial rate will also be included.
Areas Covered in the Webinar:
- Key case management roles impacting denials
- Types of clinical reviews
- Denial management
- Categorizing denials
- Key case management strategies for reducing denials
- Roles of team members
- Definition of revenue cycle
- Revenue cycle process steps
- Stakeholders
- Definitions of medical necessity
- Steps in care coordination where denials can occur
- Steps in the discharge planning process where denials can occur
- Payer expectations
- How case management causes denials
- How third party payers cause denials
Who Will Benefit:
- RN Case Managers
- Directors of Case Management
- Case Management Senior Leaders
- Directors of Finance
- Physician Advisors
- Director of case management
- Case managers
- Directors of nursing
- Directors of patient flow
- Director of revenue cycle
- Chief financial officers
- Chief operations officers
- Chief medical officer
- Hospitalists
- Director of quality management
- Nursing home directors
- Director of home care
Toni Cesta
Consultant and Owner, Case Management Concepts LLC
Toni G. Cesta, Ph.D., RN, FAAN is Partner and Health Care Consultant in Case Management Concepts, LLC, a consulting company which assists institutions in designing, implementing and evaluating acute care and community case management models, new documentation systems, and other strategies for improving care and reducing cost. The author of nine books, and a frequently sought after speaker, lecturer and consultant, Dr. Cesta is considered one of the primary thought leaders in the field of case management.
Dr. Cesta writes a monthly column called “Case Management Insider” in the Hospital Case Management journal in which she shares insights and information on current issues and trends in case management.
Prior to her current work as a case management consultant, Dr. Cesta was Senior Vice President – Operational Efficiency and Capacity Management at Lutheran Medical Center in Brooklyn, New York. She was responsible for case management, social work, discharge planning, utilization management, denial management, bed management, the patient navigator program, the clinical documentation improvement program and systems process improvement. Prior to her position as Senior Vice President at Lutheran Medical Center, Dr. Cesta has held positions as Corporate Vice President for Patient Flow Optimization at the North Shore – Long Island Jewish Health System and Director of Case Management, Saint Vincents Catholic Medical Centers of New York, in New York City and also designed and implemented a Master’s of Nursing in Case Management Program and Post-Master’s Certificate Program in Case Management at Pace University in Pleasantville, New York. Dr. Cesta completed seven years as a Commissioner for the Commission for Case Manager Certification.
Dr. Cesta has been active in the research and development of case management for over 25 years. Her research in case management has included two funded studies measuring the effects of a case management model on congestive heart failure and fractured hip patient populations, with measures of patient satisfaction, quality of life, and short and long term clinical perceptions and outcomes.
Dr. Cesta has presented topics on case management at national and international conferences and workshops. Her books include “Nursing Case Management: From Essentials to Advanced Practice Applications”, “The Case Manager’s Survival Guide: Winning Strategies in the New Healthcare Environment”, “The Case Manager’s Survival Guide: Winning Strategies for Clinical Practice”, “Survival Strategies for Nurses in Managed Care” and “Core Skills for Hospital Case Managers”. Dr. Cesta is Consulting Editor of “Hospital Case Management Journal” and “Discharge Planning Advisor”. In addition, she serves as editorial advisory board member of several case management journals and publications including “Strategies for Healthcare Excellence” and “The Journal of Care Management”.
Dr. Cesta has a BS in Biology from Wagner College, a BS in Nursing from Adelphi University, an MA in Nursing Administration from New York University, and a Ph.D. in Nursing Research and Theory Development from New York University.
Dr. Cesta is a Fellow of the American Academy of Nursing. Among her awards are included the “Nursing Service Administration Award” from the New York State Nurses Association, the Jessie M. Scott Award for excellence in research, practice and education from the American Nurses Association, and three “Book of the Year” awards from the American Journal of Nursing. In 2010, she was awarded the Brooklyn Leaders Award from the Arthritis Foundation.
Topic Background:
Third party denials of payment remain a challenge for case management departments across the country. While in the past the majority of denials came from commercial payers, today’s denials come from Medicaid and Medicare as well. The impact of denials has increased with the implementation of the two-midnight rule and the requirements associated with placing patients in the right level of care based on their medical necessity needs and expected length of stay. Loosing reimbursement as a result of denials can have a significant impact on the bottom line of any organization. Many of these denials can be prevented!!
More Training By Experts
- Bundled Payment Review: How Case Management Can Play a Strategic Role
- An Update on Discharge Planning Rules and Regulations for 2022
- How to Think Like an Accountable Care Organization - Integrating Case Management Across the Continuum
- Interdisciplinary Bedside Rounds: The State of the Art
- Compliance Measures for Case Managers
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