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Case Management in Healthcare: It’s Not Just About Patients

June 23, 2020

Case management in the healthcare industry doesn’t only pertain to the clinical side of operations. Healthcare administrators must account for different business entities and legal regulations when managing patient registration insurance contracts, coding, billing, and other stages of the healthcare revenue cycle.

These complex healthcare processes require workflows and management tools that can adapt to specific, ever-changing needs. A case management solution allows healthcare professionals to build workflows that can be customized on an ad hoc basis to serve specialized work needs and efficiently organize any series of tasks—no matter how individualized they may be.

Read on for a deeper look at the healthcare applications of case management beyond patient care.

Bridging the Clinical and Financial Sides of Healthcare

Patient care and financial/administrative workflows and tasks are always intertwined in a healthcare setting. Case management tools can help coordinate tasks, trigger actions, and promote communication between the financial and patient care sides of a healthcare organization. These tools enable seamless and responsive action to address reimbursement issues and billing and coding problems that could otherwise result in claims denials.

By facilitating better communication and collaboration, case management tools can help administrators stay in the know regarding patient care and its implications on the financial side of operations. This reduces reimbursement and billing issues, resulting in on-time payment and fewer collections actions taken by the company.

Managing a Complex Revenue Cycle

Most healthcare companies operate within tight margins that depend on efficient management of the company’s revenue cycle. Although an emphasis on revenue cycle management can apply to any business or industry, healthcare is particularly dependent on having a streamlined, detail-oriented case management approach to handling the revenue cycle. When implemented correctly, case management can improve not just the company’s financial bottom line, but also patient outcomes and patient satisfaction.

Case management spans a patient’s entire experience with a healthcare company, and even extends beyond it if billing and payment remain unresolved after the patient’s stay. The subcomponents of managing the revenue cycle, as it relates to case management, include the following:

  • Utilization management to gain approvals from payors regarding medical procedures and/or inpatient stays
  • Coding and patient status classifications to ensure consistency with both payor approvals and regulatory policies
  • Discharge planning to mitigate unnecessary timelines for inpatient stays, which can increase the risk of post-billing denials
  • Appeals processes to address post-billing denials from payors
  • Post-visit care coordination to ensure ongoing care that prevents unnecessary readmissions that generate additional costs to the payor

When complex billing or administrative tasks develop, a case management solution can be used to manage custom workflows built specifically for that instance. Through this responsive approach, a strong case management program can actually reduce the frequency of disputes, appeals, collections actions, and other events that disrupt the revenue cycle and require additional effort from the company’s case management team.

Ensuring Policy Compliance Across Administrative Activities

Healthcare organizations must manage several layers of regulation and compliance when handling both patient care and administrative tasks and information. In addition to the well-known HIPAA privacy regulation, healthcare companies may also be subject to additional local regulations, as well as policies mandated by the company’s leadership.

Performing case management amid these complex conditions requires a software solution that can build and manage complex flows while adhering to a highly intricate ecosystem of rules. Decisions’ case management solution is supported by a business rules engine that can account for thousands of business rules at any given moment. With this rules infrastructure in place, case management teams can harness the power of a dynamic, agile case management tool while implementing safeguards that guarantee compliance at every step.

Comprehensive Case Management for Your Company

A well-run healthcare organization may start with providing excellent care, but administrative and financial services are essential to supporting front-line services and improving the health and stability of the company.

Learn more about the benefits of Decisions’ case management solutions for healthcare companies—subscribe to our blog today.

Gordon Jones
Gordon Jones has founded and sold three companies with the last built using Decisions technology. He has also led factories and large IT implementations both in the US and in Asia, where he lived for over seven years.

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