Managed Care Contracts and the Case Management Leader: Leading Your Department to Improved Reimbursement

Why Should You Attend:

The contract between a payer and a hospital often includes much verbiage that is of little help to a case management leader. It is important, however that they understand the source for any requirements of the case management department. This may be either in the contract or the provider book. Understanding the contents of UM language is critical in ensuring best-practice utilization management processes.

Contracts are often viewed as mysterious documents with unknown contents to the case management department. This webinar will introduce an effective strategy to better understand the utilization management portion of a contract, as well as what the leader should expect to be included in any managed care contract between a hospital and a payer.

Additionally, understanding how we are paid is often challenging and there will be a section to provide education for case management leaders.

Areas Covered in the Webinar:

• The Healthcare Industry Today
• The Mandate to Change How and What We Are Paid
• How We Are Reimbursed
• DRGs and Length of Stay
• Rules and Regulations Driving Medicare Payment
• Value-Based Reimbursement
• Managed Care Models of Reimbursement to Hospitals
• Bundled Payments
• The Managed Care Contract
• Strategies for the Case Management Leader Regarding Managed Care Contracts
• Utilization Management Contents of Managed Care Contracts
• Understanding the Outcomes of Your Primary Payers
• Sharing Content with Your Staff, Physicians and Physician Advisor: Who, What, When Where?

Who Will Benefit:

• RN Case Managers
• Utilization Managers
• Appeal Coordinators
• Directors of Case Management
• Directors of Utilization Management
• Supervisors of Case Management, Utilization Management and
• Executives to whom these leaders report

Beverly Cunningham
Consultant, Case Management Concepts LLC

Bev Cunningham, MS, RN, ACM is a founding partner of Case Management Concepts, LLC. She has a 25-year deep working knowledge of case management with specific expertise in denials management, patient flow and the role of the Case Manager and Social Worker in the Case Management process. Bev is also a certified case manager with the American Case Management Association. She has served as a Commissioner on the Commission for Case Management Certification and is a fellow with the Advisory Board. Bev is also the former Vice President of Resource Management at Medical City Dallas Hospital.

She has co-authored a book for hospital case managers—Core Skills for Hospital Case Managers and has written the utilization management chapter in the past two editions of CMSA’s book, Core Curriculum for Case management.

Topic Background:

Managed care contracts can by scary. They are understood by very few in a hospital. Typically, case management leaders have not been a part of contract content or contract negotiations. In fact, when approaching those in a hospital who are responsible for contracts there is often a “push back” to sharing information in these contracts. A case management leader must be very clear what part of the contract they are requesting.

It is difficult to lead a department that is providing utilization management processes with a payer and have absolutely no idea what is being required by that payer. Thus, this webinar is of utmost importance in assisting case management leaders in understating how we are paid, what impacts what we are paid and how to ensure that the department is pursing best-practice collaboration with the payer in providing information regarding their members’ hospital stays.

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