1

ACM™ Certification Prep Manual

Developed by:

Nancy J. Loeffler RN, BSN, ACM, CCM

Please Note:

The ACM™ Certification Prep Manual, study group presentation, case studies and review test were developed by ACM Study

Group facilitator, Nancy J. Loeffler RN, BSN, ACM, CCM, and are provided as a complement to the ACM Study Group at the

2013 ACMA National Conference. Though this information references ACMA resources and publications (including, but not

limited to: the “Standards of Practice & Scope of Services,” and the “ACM™ Candidate Handbook”), it was not developed, nor

is it endorsed by, the American Case Management Association (ACMA). These materials are intended to aid ACM candidates in

exam preparation. The facilitator does not have access to the ACM exam or a study guide for the exam, and these materials,

along with participation in the ACM Study Group, do not guarantee a passing score. These resources are intended to supplement

an ACM candidate’s exam preparation.

Preparing for the American Case Management Certification examination requires

attention to detail and a clear understanding of the case management process. The examination

is divided into two distinct sections as evidenced in the ACM™ Candidate Handbook. The

handbook supplies the learner with helpful hints and practice sample questions and clinical

scenarios are supplied for downloading and computer simulation. The handbook outlines the

types of questions presented during the certification examination and also gives the required

information on applying for the examination. The exam is given multiple times throughout the

year and there are certain deadlines for applying for the exam. The information and the handbook

are available on the ACMA website: www.acmaweb.org/acm.

When studying for the examination, one should take into account the exam is given to all

case managers in every health care area with emphasis on case managers and social workers who

practice in acute care settings and long term acute care facilities. Two types of exams are given,

one for nurse case managers and one for social work case managers, each testing the expertise of

the individual field.

Studying for the exam should follow the case management process. Screening,

assessment, planning, care coordination, outcomes management, and understanding regulatory

issues are some of the main areas of study. The case management process is followed and

practiced in small hospitals and large health systems and studying for the exam should follow the

process, not the individual hospitals and health systems practices. Case scenarios are presented

to test your knowledge of the case management process and each question within the scenario

builds on the previous question and answer. Example scenarios will be presented.

2

There are two sections of the examination. One section covers the multiple choice

examination that evaluates your general knowledge of the case management process, and for

social workers, the psychosocial aspects of case management. The second section tests your

ability to properly apply the case management process through case studies.

This manual will give you a general overview of the features of the exam. Practice

questions and scenarios/case studies will give general types of questions posed in the multiple

choice section and the case studies section.

Scopes and Standards of Practice

The essentials of case management are grounded in the scopes and standards of practice

as defined by the American Case Management Association. The scope of services encompasses

advocacy and education, clinical coordination and facilitation, continuity of care and transition

management, financial management, performance and outcomes management, psychosocial

assessments, research and practice development, and utilization management. The standards of

practice include collaboration, communication, facilitation, coordination, advocacy, resource

management, accountability, and professionalism (ACMA, 2008).

Discussing each of these as it relates to the case management process means

incorporating the concepts into daily practice. Case managers are the central axis in the hospital

setting. Their function is to reach across several areas of the hospital setting such as registration

or pre-admission screening, financial management, outcomes management, care coordination,

using resources properly affecting the cost per case, length of stay, and following the regulatory

guidelines of the federal payers. Case Management continues to evolve as an essential aspect of

acute care and with the introduction of new legislation and a greater segment of the population

being insured, the responsibilities will span evaluations of re-admissions for all causes and ways

to avoid them and extensive planning for chronic disease management. The term case manager

3

refers to both nurses and social workers in this context. The scope and standards of practice will

be addressed as it relates to the examination in four distinct areas; screening and assessment,

planning, outcomes management, and regulatory issues.

Attributes of an Effective Case Manager

There are certain attributes of nurse and social work case managers that create an

effective case manager. Certainly having a nurse with a solid clinical background and

knowledge of clinical issues and disease processes maximizes the communication between the

medical team and the nurse case manager. Equally important is the communication and

assessments skills of the social work case manager assisting patients accepting care and helping

the patient and families work through difficult disease processes or traumatic injury resulting in

alteration of body image and independence. Proper reporting of abuse and neglect is the

responsibility of both nurse and social work case managers. When the nurse and social work

case manager work together collaboratively as a team and communication is optimized, the

patient is the recipient of excellent care and post-discharge sustainability.

Case Managers are first and foremost patient advocates. Daily activities include

coordinating benefit plans, requesting family meetings, coordinating care with the medical team,

advocating for the patient with decisions surrounding care, refusing care, accepting care, or

withdrawing care. Breaking down financial, social, or emotional barriers are the first steps in

creating a trusting relationship with the patient and the medical team. The Case Manager is the

center of the medical universe as it relates to patient care coordination. Case Managers must

4

work autonomously coordinating care with the medical team providing patient-centered care.

Communication skills are a top priority when assessing a potential case management candidate.

Because Case Managers cross so many aspects of the patients care, the ability to communicate

effectively with everyone on the team is paramount. The external team of insurance providers

and vendors need to have the pertinent information to coordinate benefits, create a benefit when

a cost-benefit analysis is completed, and provide clinical information to the vendor so equipment

and medical care continues as ordered and understood.

Screening and Assessment

Screening and assessment begin with explaining the purpose of case management and

what services are provided for patient safety and health. Proper introductions and securing a

time when the patient is engaged and free of distractions is essential to efficient transitional

planning. The case manager should set aside personal feelings or beliefs that may invade the

assessment process and ask open ended questions to obtain information as it is the most efficient

in discovering what the patient is thinking and feeling about the present situation. Screening and

assessment goes beyond the hospital experience and embraces the patient’s lifestyle and

cognitive abilities, understanding the disease process, and setting expectations. This is especially

important when coordinating insurance benefits with transitional planning. While Medicare does

not serve as a total financial basis for transitional planning, one must keep in mind what is

possible if the patient is in the hospital for observation services. There still exists the myth of

Medicare covering long term care and personal services. All commercial carriers do not

necessarily have coverage for skilled care in a facility and may have extensive home care

benefits. Coordinating services is having a full and detailed understanding of the patient’s

benefits as well as federal payers’ rules and restrictions for transitional planning. The goal of

5

every case manager is to fully understand coordination of benefits and advocate for the patients

in their care. It may mean negotiating with the payer if possible to enhance or create a benefit if

a cost-benefit analysis presented assures the payer of some cost savings and a possible avoidable

readmission in the future. The analysis is important in advocating for your patient’s well-being

in a transitional model that encompasses pre-screening to post discharge follow-up.

Prescreening:

Patients arriving for scheduled services often require precertification and prescheduling

services. This is a time for the case managers to become involved in the discharge planning

aspects for those patients considered high risk for services post discharge. Some examples

would be the scheduled hip and knee surgeries, colorectal patients with extensive surgeries,

transplants, and patients adjusting to a new and possible life altering diagnosis such as cancer or

neurological disorder. These patients present at a vulnerable time in their lives and reaching

them prior to admission may increase their understanding of the discharge process, services

available post discharge, and those services that would be most applicable to the needs.

Assessing patients at pre-admission allows an introduction to the case management process and

relationship building without the back ground noise and distractions of hospital activity. Family

members can be involved with the preliminary decisions and the patient and the family can be

aware of the next steps after admission.

The case manager can coordinate with the patient’s insurance benefit coverage for post

discharge services and ensure coordination of care with benefit availability. Documentation of

6

post discharge planning in the patient record conveys the message to the health care team that

prescreening has occurred and case management has been involved.

Prescreening can also occur in the emergency department as more facilities have

expanded case management in that area. Speaking with families and patients during the time in

the emergency department provides a basis upon which to build the case management process

with patients and families. Important information may be obtained upon which to build a

transitional plan. Contact information and barriers to discharge can be discussed and preparation

for breaking those barriers can begin prior to admission. While not every patient is admitted

from the emergency department, it is at this time the case manager can intervene and provide a

viable transition plan out of the emergency department. Alternatives to admission can be offered

to physicians and other health care team members to avoid an inappropriate placement to the

acute setting, even in light of observation services that can be overused or misused in some cases

of social issues.

Admission screening and assessment:

Case managers have many sources of information from which to gather pertinent

information about the patient. Physician’s history and physical assessments, medical

documentation from the patient’s chart, interactions the patient has with the clinical nurse, and

assessments from services such as pharmacy, physical, occupational, speech, and nutritional

services provide a solid basis for transitional management. Encounters by other case managers

during previous hospitalizations can assist the case manager in understanding the plans finalized

for previous transitional planning and evaluate the effectiveness and sustainability of those plans.

It is imperative to review the previous plans and build upon the successes and eliminate options

7

that did not meet the patient’s needs. Preliminary information from the emergency department

case manager should eliminate redundant inquiries of basic information from the patient and

family. Building upon previous information increases patient engagement and eliminates patient

fatigue by eliminating repetitive questioning. Unless it is for clarification, the case manager

should only verify and quantify previous information and build upon that information to

formulate a plan of action.

The best source of information is the patient and family. The case manager can assess

cultural and religious beliefs, family values and support, and barriers to transitional planning.

Reaction to the disease process can be observed through responses to open-ended questions.

Understanding the medical management of the patient’s disease process is paramount to

transitional planning and expectations from the physician and the patient should be realistic and

understood by all members of the health care team. Communication to the patient should be on-

going and must contain the same consistent information to assure the patient everyone on the

health care team is actively involved in the patient’s care. Consistent communication builds trust

with the patient and makes transitional planning less difficult. When the patient knows the plan

of care and what milestones are to be met prior to discharge, the transition can be seamless and

assures the patient and family that all members of the health care team have assured the best care

possible has been given. The trust in the team flows over into the after care in that the patient is

more engaged in following the plan post discharge knowing everything possible was done during

the hospitalization and the team practiced patient-centered care.

Information Gathering

8

Case Managers have many rich resources of which to avail themselves. The health care

team consists of not only those who provide direct care to the patient but also those in the

community who may have a relationship with the patient. If the patient has received services

from a community clinic or has a community social worker, information is available to the case

manager to continue with services already established. In each case, the patient must consent to

contact with the providers outside of the acute care setting. Violation of the patient’s privacy

without consent will create distrust and the possibility of less engagement in the transition

process. Working as a patient advocate means working within the constraints of patient’s

privacy and wishes.

Considerations:

There are certain areas to consider when gathering information. Fully understanding these areas

allows the case manager to create a transitional plan that is safe, effective, and sustainable. It is

patient-centered and based on the information received from the patient. Information

surrounding the patient’s support system and financial concerns will assist in proper planning.

Other considerations are:

Religious or faith based beliefs.

Cultural beliefs, traditions, and customs especially those surrounding end-of-life

decisions.

Understanding of the disease process and treatment plan.

Likely outcome of treatment.

Acceptance of a chronic or incurable disease process.

Housing and prior functional status.

9

Level of independence.

Cognitive ability and level of education.

Occupation and the patient’s ability to return to work or prior function.

Interventions which required body alteration such as amputations, disfigurement, or

physical trauma.

Abuse and neglect whether physical, psychological, or emotional.

Assessing a patient’s needs for transitional planning should be conducted at a time when it is

convenient for the patient and hospital activities are not distracting the patient from interacting

with the case manager. This creates better patient engagement as well as a comprehensive

screening and assessment.

Planning

Transitional planning is based on the information obtained through the screening and assessment

process and is coordinated with the, patient, family, care team, patient’s support system, and

payer if applicable. There is an acronym case managers should follow when planning, SMART

S- Specific

M- Measurable

A- Achievable

R- Realistic

T- Timely

Specific planning is patient-centered and designed to keep the patient healthy, compliant with

a health-treatment regimen, and using less costly community services over acute care hospital

services. Using case managers at the commercial payer source will keep the patient in contact

10

with services and provide a contact for the patient should there be concerns post discharge. For a

patient without a payer source, available community resources must be researched and obtained

prior to transition from the acute care setting. Follow-up care is arranged through a community

clinic or the patient’s primary care provider. In many areas, disease specific clinics are available

for congestive heart failure patients, diabetics, pain clinics for patients experiencing chronic pain,

partial day programs for mental health patients, day care centers for Alzheimer’s patients, and

private services for patients with no support system. Life planning is also part of transition

planning for patients unable to remain at their prior level of function. Arranging for assisted

living, long term care, or private services for families gives options to patients and families

facing a change in lifestyle and function.

Measurable values means the planning is appropriate and sustainable. The external and

internal sources of services provide a solid basis for the patient and family to sustain the patient

at the level of care appropriate for the patient and family. It allows the patient to be compliant

with the treatment plan and regimen started in the acute care setting. Measurable results are

viewed through readmission statistics, number of avoidable emergency room visits, and cost of

care per patient. The case manager must not be too eager to transition a patient before proper

plans are in place and agreed upon by all parties involved. Early intervention and planning as

well as alternate plans should be in place early in the hospitalization to assure a timely, safe and

appropriate discharge when the patient is medically cleared.

Achievable results are measured by being prepared for transition when the patient is

medically stable for the next level of care. Community resources and health care teams are in

place to care for the patient at whatever level is appropriate. When discharge orders are written,

a viable plan is in place that is safe, appropriate and sustainable.

11

Realistic is working within the patient’s payer benefit plan or financial contraints. Assigning

a patient to private services uncovered by a payer or other financial resource may mean the

patient will be unable to sustain care and in turn, unable to sustain the transition plan arranged by

the case manager. A more realistic approach is to find an avenue in which to provide care using

the resources available that are cost effective and readily available. Crucial conversations are

essential in the planning stage assuring the patient and the health care team understands the

barriers and the opportunities open for transitional planning. Without the buy-in and complete

understanding of what is available and sustainable, medications, prolonged care, and treatments

may be ordered that are unrealistic for the patient, family, and care givers. Impossible

expectations set-up patients and families for failure and develop trust issues between the patient,

family, and case manager. As patient advocates, every case manager must keep the patient first

and foremost in every stage of evaluation, planning and outcomes. Case managers must update

their knowledge of new and available resources constantly. Reading case management journals,

attending community events, and joining a case management professional organization that holds

regular meetings can assist case managers in networking with other professionals who have

solved difficult transitional plans and can share their experiences.

Timely assessment and planning is imperative to timely transitions. Delay in any aspect of

screening and planning delays skilled facilities, inpatient rehabilitation facilities, home health,

and private services from accessing the patients benefits for prior authorization or reviewing and

evaluating patients for level of care. Complex planning for home ventilator patients, babies and

children with complex needs transitioning from the neonatal units to home often have difficult

and intricate home needs and complete coordination of care between durable medical equipment

companies for oxygen, home ventilators, tube feedings, pain pumps, hospital beds, and other

12

supplemental supplies requires coordinating with the vendors and families ensuring all the

supplies are available when the patient arrives home. Arranging time for the families to meet

and interview the vendors creates a level of comfort with the plan and the service provider.

Internal and External Sources

During the planning phase of transitional care, the case manager has resources available from

internal and external sources. Internal sources are the attending physician or primary care

physician, the hospital care team, and the experts assisting in the patient’s care. This can be the

clinical nurse, ancillary services, pharmacy services, pastoral care, the patient/customer relations

department, and hospital administration. Risk management may be involved in certain cases

when the family or legal representative is unwilling to fulfill the duties of a POA and change the

wishes of the patient when the patient can no longer speak for him/herself.

External sources are the vendors and facilities available to the patients. Patients do have a right

to choose providers for their transitional care. A case manager also has the responsibility to

provide the most reliable providers within the patient’s network. Knowingly using a provider

who consistently provides suboptimal care or who states they can provide the necessary services

and then does not make contact with the patient violates the advocacy standards of case

management. Providing a safe, appropriate, and sustainable transitional care plan is essential to

the patient’s well-being while preventing readmissions.

Psycho-Social Assessments and Screening

13

A complete psycho-social assessment delves deep into the heart of the patient. Patients

will either be reluctant to speak to a stranger or be open and honest during the assessment. An

assessment begins with building rapport with the patient and the family if available and the

patient agrees.

Types of items to assess:

Support systems, formal and informal

Type of living arrangements, single family home, stairs in the home, access to cooking

facilities

History of mental illness

New diagnosis of debilitating disease or a disease complicating independence

Educational level and cognitive level of understanding

Inappropriate reactions to hospitalization or reluctance to leave the hospital

Stressors such as a new diagnosis, divorce, recent death in the family or inability to

accept death of a loved one.

Level of independence prior to hospitalization, use of any durable medical equipment

such as a walker, cane, wheelchair, etc.

Reaction to family members or care givers to the current hospitalization or diagnosis.

Religious or cultural beliefs affecting health and wellness

Case Finding

Different organizations have different methods of case finding. Case finding is defined

as assessing patients for risk of discharge needs or interventions required during the

hospitalization that may affect a safe and appropriate discharge. Case finding varies in

14

organizations based on the population it serves. Patients may be prioritized based on age,

diagnosis, mental illness, support systems, etc. Some models request case managers see every

patient on the unit if the case managers are geographically-based, other organizations identify

patients at risk and determine whether a social work case manager or a nurse case manager may

be more appropriate to see the patient and then coordinate care between psych-social needs and

medical needs.

Case finding includes:

Age > 65 or 70

Disability

Mental illness impacting hospitalization

Patient with underlying diagnosis of dementia

Length of stay > 5 days

Co-morbid conditions impacting hospitalization

Lack of payer source or patient experiencing financial difficulties

Lack of primary care physician and use of multiple consults

Re-admission within 15-30 days or more frequently if noted

First time mothers lacking pre-natal care or lack of sufficient emotional, financial, or

social support. This may include follow-up care, child care, housing, and lack of pediatric

care post discharge.

Outcome Management

Positive, measurable, and sustainable outcomes are the result of case managers following the

case management process. Setting up reports on which to measure outcomes involves:

15

What is measured.

How it is to be measured.

The frequency of measurement.

The length of time data will be collected

The baseline of the measurement

The comparison or benchmark

What is it the department or organization wants to achieve?

The mistake most made by departments or organizations is too much data is collected and there

is no clear objective in how and why the data is collected. When too much data is collected and

is not specific, it is just information for information purposes. A clear understanding of

objectives, what questions need answering, and the type of data gathered is the basics of essential

outcomes measurement. If a Chief Financial Officer asked the case management department if it

was efficient the data to be gathered would be based on the cost of the case by patient. If the

patient received appropriate care and the appropriate time and was discharged with services

associated with avoiding a readmission, and unnecessary testing or delays in treatment would be

reflected in the cost per case. Another data capture could be the number of denials a department

receives. If the leadership within the department can show with data capture that it is

understaffed and the number of payment denials is directly related to understaffing, it makes a

more compelling argument to increase staff doing utilization or create a better ratio if the

department is doing total care coordination. There are many different staffing models in case

management and outcomes management must be based on the type of data gathered based on the

model used.

16

Gathering data on readmission is imperative with the new health care regulations

indicating re-admissions for any cause will decrease reimbursement. If efficient in keeping

patients compliant and in the community seeking outpatient care is gathered correctly, the data

will reflect the efficiency. Data may also be gathered on what programs are efficient in

preventing readmissions and build upon those successes. Outcomes management is imperative

in operating an efficient and highly effective case management team. The knowledge gained

from outcome management assists the case manager in providing high quality care using

resources effectively in the acute care setting.

Care Coordination

Care coordination is the very basis of case management. Case Managers coordinate

insurance benefits, medical care, family issues, discharge planning, end-of-life issues, and psych-

social issues. It involves every aspect of patient care and is essential in providing a safe,

sustainable, and appropriate discharge plan. With the advent of reimbursement contingent on

patient satisfaction scores, the case manager must be mindful of the ramifications of improper

care coordination. Delays in care, inefficient hospital care or department delays increases the

cost of the case and delays the discharge planning process, frustrating patients and families and

creating a trust issue. The care team often seeks the advice and guidance from the case manager

on the care team to be the problem solver. Cooperating with hospital departments means

building relationships with the persons who can assist in getting things done. Proper

communication is the accelerator in getting what the patient needs and making the care team

cognizant of the assistance needed to move the patient through the system appropriately and

safely.

17

Total care coordination includes communication with the care team consisting of the

physicians, clinical nurses, disease management coordinators, pharmacy, ancillary services, and

even the environmental department. Too often the case manager can overlook the simplest of

details that can create the best throughput. When a patient is admitted, activities are set in

motion requesting clinical care, medications, consults to specialists, ancillary services, radiology,

laboratory, and usually, case management. Based on an initial assessment by the case manager,

a pastoral consult or risk management consult may be required. If a quality of care issue arises,

including the quality department to investigate may be in order. Palliative care or hospice may

be involved if pain control or end-of-life concerns arise. Case Managers have the knowledge to

coordinate care with all disciplines affording a positive experience for the patient and advocating

on the patient’s behalf.

Care coordination begins when the patient arrives and does not end until the patient has

received all the necessary care and has a safe, appropriate, and sustainable discharge. No matter

what model is used in the organization, care coordination is based on excellent and continued

communication. Geographically based case managers have the advantage of being part of an

established care team and being available on the unit daily. In the triad model of social worker,

discharge planner, and utilization review manager, constant communication must be done to

assure the patient is receiving necessary services within the confines of the payer benefit plan. If

communication fails between any one of the three managers, the patient care may be

compromised. If a case manager follows a service line, communication may be enhanced as the

case manager has constant contact with the care providers. No one model is better than another.

Modeling a case management department for care coordination depends upon the organization’s

mission, vision, and goals.

18

Regulatory Issues

Understanding the regulatory issues placed on acute care hospitals must begin with a

historic perspective of legislation and its impact on acute care hospitals are discussed.

Hill Burton Act of 1946

The purpose of the Hill Burton Act was to build hospitals in areas underserved and in

rural areas. Federal funds were earmarked by the fund with the stipulation if federal funds were

accessed, a certain percentage of the care provided by the hospital would be charitable. The

percentage was based on the number of admissions and the area served. The types of hospitals

case managers work in today are either for profit or not-for-profit venues and have developed

since the law passed and provided funds.

Social Security Act 1965

The Social Security Act of 1965 provided medical care to those aged 65 and over. At the

time the law was passed, life expectancy was 72 for males and 75 for females. Since 1965, the

average life expectancy has increased ten to twelve years. Social Security is funded through tax

payers’ payroll contributions. Each year, the percentage assessed from wages has increased to

cover the cost of Medicare funding and benefits have been more restrictive. The emerging baby

boomer market will place an increasing burden on the Medicare trust fund as evident by

Congress to solve the threat of the Medicare trust fund becoming insolvent.

19

The Social Security Act was divided into two distinct parts. Title XVIII was Medicare

and provided inpatient care, sub-acute care under Medicare Part A and physician services and

outpatient care under Medicare Part B. Title XIX was formed and named Medicaid serving those

patients who needed public assistance and were under an established income level.

Medicare Revision 1978 Added ESRD

In the 1960’s Dr. Belding Scribner invented the dialysis shunt to attach to a dialysis

machine removing toxic waste from the human body. By 1978, a revision to Medicare contained

a provision covering patients in end stage renal disease awaiting transplants. It was then

expanded for coverage three years post-transplant. ( See Medicare coverage)

Social Security amendment 1983 DRGs established

In 1983, the federal government established Diagnostic Related Groupings as a form of

payment. Payment is based upon diagnosis and what a highly efficient organization can expect to

be paid based on the care and services provided. It is a bundled payment. We manage care and

receive one lump payment. Some weight-based payment is given based on the number of co-

morbid conditions and may increase the payment amount. Documentation is paramount to

receiving an additional amount for co-morbid conditions and the treatments provided that

impacted the patient for the inpatient hospital stay.

EMTALA 1986 access to medical care regardless of payment source

The Emergency Medical Treatment and Active Labor Act requires hospitals to provide a

medical screening for a patient who seeks medical care regardless of their ability to pay,

citizenship status, or legal status. Any hospital participating in the Centers for Medicare and

20

Medicaid plans and the Department of Health and Human Services may only transfer or

discharge patients needing emergency treatment under their own informed consent, after

stabilization, or when their condition requires transfer to a hospital better equipped to administer

the treatment. The Act was passed after blatant situations were taken to court and hospitals were

found guilty of “patient dumping” i.e. patients with an inability to pay for care were sent to

another hospital for care and treatment even though there was evidence of instability and a high

risk of further injury or illness without proper medical screening prior to transfer.

Patient self-determination act:

The right to facilitate their own health care decisions

The right to accept or refuse medical treatment

The right to make an advance health care directive

The three rights listed are the essential elements of the Patient Self-Determination Act and was

passed in 1990 as part of the Omnibus Budget Reconciliation Act of 1990. It requires hospitals,

home health agencies, skilled nursing facilities, hospice agencies, and HMOs to inquire whether

the patient has an advance directive or a living will. Some organizations provide a service for

patients wishing to complete one when accessing services.

HIPAA 1996

The Health Insurance Portability and Accountable Act of 1996 protects health insurance

for persons and families when changing jobs and allows patients to keep the coverage under

COBRA or provide evidence of credible coverage when moving from one organization to

another. The emphasis of the act was on creating and establishing standards for electronic health

records and information. A covered entity may disclose protected health information (PHI) to

facilitate treatment, payment, or health care operations however it must also insure PHI is

21

protected when transporting by any means. Storage of PHI must be secured from intrusion and

oversight of the storage area must be maintained and records secured.

Providing necessary medical information to payers must follow the Act securing a quiet

area if using telephonic reviews and assuring fax information is secure and fax numbers have

been validated prior to faxing any PHI to a payer. Organizations have Compliance Officers

monitoring compliance to the Act and investigating possible violations. Violations may be

reported without retaliation. Immediate dismissal of staff can occur if the occurrence is in clear

violation of the law.

Balanced Budget Act of 1997

The Balanced Budget Act provides preventive care and screening, diabetic education and

supplies, and Medicare Risk plans are now Medicare Advantage plans and HMOs. Over $112

billion in cuts for Medicare occurred because of the Act to balance the budget and provide for

continuance of the Medicare Trust Fund. It is thought of as the precursor to the Patient Protection

and Affordable Care Act.

Patient Protection and Affordable Care Act of 2010

PPACA was signed into law on March, 2010, and includes numerous provisions to take effect

over several years beginning in 2010. Policies issued before the law was signed are

grandfathered from most federal regulations. A check list of the highlights of the program

affecting case managers is listed:

Guaranteed issue and partial community rating will require insurers to offer the same

premium to all applicants of the same age and geographical location without regard to

most pre-existing conditions (excluding tobacco use).

22

A shared responsibility requirement, commonly called an individual mandate,

requires that all persons not covered by an employer sponsored health plan, Medicaid,

Medicare or other public insurance programs, purchase and comply with an approved

private insurance policy or pay a penalty, unless the applicable individual is a

member of a recognized religious sect exempted by the IRS, or waived in cases of

financial hardship.

Medicaid eligibility is expanded to include all individuals and families with incomes

up to 133% of the poverty level along with a simplified Children’s’ Health Insurance

Program (CHIP) enrollment process.

Health insurance exchanges will commence operation in each state, offering a

marketplace where individuals and small businesses can compare policies and

premiums, and buy insurance (with a government subsidy if eligible).

Low income persons and families above the Medicaid level and up to 400% of the

federal poverty level will receive federal subsidies on a sliding scale if they choose to

purchase insurance via an exchange (persons at 150% of the poverty level would be

subsidized such that their premium cost would be of 2% of income or $50 a month for

a family of 4).

Minimum standards for health insurance policies are to be established and annual and

lifetime coverage caps will be banned.

Firms employing 50 or more people but not offering health insurance will also pay a

shared responsibility requirement if the government has had to subsidize an

employee's health care.

23

Very small businesses will be able to get subsidies if they purchase insurance through

an exchange.

Co-payments, co-insurance, and deductibles are to be eliminated for select health care

insurance benefits considered to be part of an "essential benefits package" for Level A

or Level B preventive care.

Changes are enacted that allow a restructuring of Medicare reimbursement from "fee-

for-service" to "bundled payments."

Additional support is provided for medical research and the National Institutes of

Health (NIH).

Payers and Medical Coverage

Yearly updates are available to Medicare Recipients through the Medicare and You Handbook

(by year) and are accessible to case managers through the Medicare website:

http://www.medicare.gov/medicare-and-you/medicare-and-you.html

Medicare Part A Coverage:

No premium per month. Benefits Periods:

Starts when patient enters the hospital

Ends when there has been a break of at least 60 consecutive days since

inpatient hospital or skilled nursing care in a SNF was provided

No limit to number of benefit periods/lifetime

Inpatient hospital care limited to 90 days during a benefit period

Co-payment required for days 61-90

24

Lifetime Reserve Option (60 total additional days–non-renewable)

There is co-payment required for each day of Lifetime Reserve used

There is an inpatient hospital deductible associated with each benefit

period

Short Term Acute, Long Term Acute and Inpatient Rehab hospitalizations use

the same benefit days. This can dramatically limit the number of days a

patient has available for continued treatment during a benefit period

People can buy Medicare Part A for $441 a month (rate for 2013)

Patient pays all costs for each day after the lifetime reserve days.

Inpatient mental health care in a psychiatric hospital is limited to 190 days in a

lifetime.

Hospital Stay

In 2013, you pay:

$1,184 deductible per benefit period

$0 for the first 60 days of each benefit period

$296 per day for days 61–90 of each benefit period

$592 per “lifetime reserve day” after day 90 of each benefit period (up to a

maximum of 60 days over your lifetime)

End Stage Renal Disease Medicare Coverage and Eligibility under Medicare Part A

25

Individuals are eligible for Part A if they receive regular dialysis treatments or a kidney transplant,

have filed an application, and meet one of the following conditions:

have worked the required amount of time under Social Security, the Railroad Retirement

Board, or as a government employee; or

are getting or are eligible for Social Security or Railroad Retirement benefits; or

are the spouse or dependent child of a person who has worked the required amount of

time under Social Security, the Railroad Retirement Board, or as a government employee;

Are receiving Social Security or Railroad Retirement benefits.

Part A coverage begins for ESRD:

the 3rd month after the month in which a regular course of dialysis begins; or

the first month in which a regular course of dialysis begins if the individual engages

in self-dialysis; or

the month of kidney transplant;

Two months prior to the month of transplant if the individual was hospitalized during

those earlier months in preparation for the transplant.

Retrieved from:

http://www.cms.gov/Medicare/Eligibility-and-

enrollment/OrigMedicarePartABEligEnrol/index.html

Skilled Nursing Facility

In 2013, you pay:

26

$0 for the first 20 days of each benefit period

$148 per day for days 21–100 of each benefit period

All costs for each day after day 100 of the benefit period

Medicare Part B

Part B Monthly Premium

You pay a Part B premium each month. Most people will pay the standard premium amount.

However, if your modified adjusted gross income as reported on your IRS tax return from two

years ago is above a certain amount, you may pay more.

Part B Deductible - $147 per year

If Your Yearly Income in 2011 was

File Individual Tax Return File Joint Tax Return You pay

$85,000 or less $170,000 or less $104.90

above $85,000 up to

$107,000

above $170,000 up to

$214,000

$146.90

above $107,000 up to

$160,000

above $214,000 up to

$320,000

$209.80

above $160,000 up to

$214,000

above $320,000 up to

$428,000

$272.70

above $214,000 above $428,000 $335.70

Medicare Part D Prescription Drug Plan

The chart below shows your estimated prescription drug plan monthly premium based on your

income. If your income is above a certain limit, you will pay an income-related monthly

adjustment amount in addition to your plan premium. The prescription drug plan’s donut hole

27

will be eliminated by 2020 and decreases in deductible until that time. The 2013 national

premium for prescription drug coverage is $31.17.

If Your Yearly Income in 2011 was

File Individual Tax Return File Joint Tax Return

$85,000 or less $170,000 or

less

Your Plan Premium

above $85,000 up to

$107,000

above $170,000 up to

$214,000

$11.60 + Your Plan

Premium

above $107,000 up to

$160,000

above $214,000 up to

$320,000

$29.90 + Your Plan

Premium

above $160,000 up to

$214,000

above $320,000 up to

$428,000

$48.30 + Your Plan

Premium

above $214,000

above $428,000 $66.60 + Your Plan

Part D Supplemental Information

Costs in the coverage gap

Most Medicare Prescription Drug Plans have a coverage gap (also called the "donut hole"). This

means there's a temporary limit on what the drug plan will cover for drugs.

Not everyone will enter the coverage gap. The coverage gap begins after you and your drug plan

have spent a certain amount for covered drugs. In 2012, once you and your plan have spent

$2,930 on covered drugs (the combined amount plus your deductible), you're in the coverage

gap. This amount may change each year. Also, people with Medicare who get Extra Help paying

Part D costs won’t enter the coverage gap.

28

Once you enter the coverage gap, you get a 50% manufacturer-paid discount on covered brand-

name drugs. Although you'll only pay 50% of the price for that brand-name drug, the entire price

will count as out-of-pocket costs which will help you get out of the coverage gap.

Example

Mrs. Anderson reaches the coverage gap in her Medicare drug plan. She goes to her pharmacy to

fill a prescription for a covered brand-name drug. The price for the drug is $60 and the

dispensing fee is $2. Once the 50% discount is applied, the cost of the drug is $30. The $2

dispensing fee is added to the $30 discounted amount. Mrs. Anderson will pay $32 for the

prescription, but the entire $62 will be counted as out-of-pocket spending and will help Mrs.

Anderson get out of the coverage gap.

You'll also pay only 86% of the plan's cost for covered generic drugs until you reach the end of

the coverage gap

Example

Mr. Jones reaches the coverage gap in his Medicare drug plan. He goes to his pharmacy to fill a

prescription for a covered generic drug. The price for the drug is $20 and there is a $2 dispensing

fee that gets added to the cost. Once the 14% coverage is applied to the $22, he will pay $18.92

for the covered generic drug. The $18.92 amount he pays will be counted as out-of-pocket

spending to help him get out of the coverage gap.

If you have a Medicare drug plan that already includes coverage in the gap, you may get a

discount after your plan's coverage has been applied to the price of the drug. The 50% discount

for brand-name drugs will apply to the remaining amount that you owe.

Example

29

Mr. Green is in a drug plan that offers a 60% discount on brand-name drugs (after he has spent a

certain amount), and he fills a $100 brand-name prescription. The cost of his prescription after

his plan's savings is $40. The 50% discount is applied to the $40 amount and he will pay $20 for

the prescription. The $40 will count as out-of-pocket spending and help him get out of the

coverage gap.

Items that count towards the coverage gap

Your yearly deductible, coinsurance, and copayments

The discount you get on brand-name drugs in the coverage gap

What you pay in the coverage gap

Common Regulations for Accessing Medicare Coverage

There are common regulations Case Managers must know to do transitional care planning for

their patients. The most common of these are:

The three day rule states a Medicare patient must have three medically

necessary over nights to qualify for a covered stay in a skilled facility and

receive care under the Medicare skilled benefit.

If the patient does not have a current qualifying stay, the case manager may

access previous records to screen the patient for a previous qualifying stay

within the last 30 days.

Medicare patients can receive services in a skilled facility under Medicare Part

B and pay privately for room and board if they do not qualify under the three

overnight rule. These services consist of physical, occupational, and speech

therapy.

30

Observation services do not qualify a Medicare recipient for skilled nursing

facility payment as observation services are considered outpatient services.

Patient’s inpatient admission begins when the attending physician writes a

proper dated, timed, and signed order for inpatient services and the patient

qualifies for inpatient services based on treatment modalities and presenting

disease process.

Order dated, timed, and signed by the attending physician or when the

telephonic order is authenticated.

Patient may be changed from inpatient class to observation services under

Condition Code 44 if the patient does not meet criteria for inpatient services.

Physician Advisor services must be accessed to confirm Condition Code 44 and

the attending physician must agree. Observation time begins at the time the

observation order is written and is properly dated, timed and signed.

Commercial Payer Sources:

Case managers advocate for their patients in many ways. When dealing with commercial

insurers, case managers must be hyper-vigilant of the patient’s benefits, limits, coverage, and if

there is a case manager to follow the patient post-discharge, arranging follow-up care with the

payer’s case manager. In rural areas where providers are in short supply, insurance case

managers are a life line for continued monitoring and coaching for chronic disease management.

When patient’s experience a life altering event such as a trauma or new diagnosis of cancer or

incurable neurological disorder, the payer’s case manager can manage benefits and enroll

patients in programs either in the community or in a health services organization specializing in

health and wellness.

31

Types of Payers:

There are several types of insurance plans from which to choose if a patient is covered under an

employer based plan or if the patient is privately paying for coverage. Listed are the types and

basic coverage terms the payer offers.

Liability plan: Covers for bodily injury and property damage

No-fault insurance: Typically encompasses auto and worker’s compensation insurance

Accident and Health Insurance: Pays for health care related costs and often has a lifetime

maximum. May include long and short term disability coverage.

Indemnity plans: Pays on a fee-for-service basis and the patient has the freedom to

choose providers with no increase in deductible or co-pays.

HMO: Health Maintenance Organizations are equipped to handle patients’ benefits for a

fixed amount each month. Patients are required to use physicians who have agreed to provide

care to the patient based on a fee schedule and a fixed amount for coverage. Precertification is

needed for scheduled inpatient services and specialty services such as cardiology, endocrinology,

and so on. Care is provided under a Preferred Provider Organization (PPO) and physicians are

part of a part of a large practice or group and they contract with the insurer for a fixed fee. An

Independent Practice Association (IPA) is one in which physicians who own their own practice

negotiate fees with payers and maintain their independent practice. Point of Service contracts

allow the covered individual more choice in the physicians they see, however coverage may be

better and deductibles may be lower if the patient accesses a physician or physician group within

the network. Usually premiums are higher but the choice of providers is larger and may

encompass specialists without a referral.

32

Types of Reimbursement:

Fee –for-service: No pre-arranged contract exists and payment is made on charges

incurred and billed.

Per Diem: Payment is made by the average cost per day and the number of days care was

provided regardless of charges

Percent of charges: Fixed payment is made based on charges on the hospital bill.

DRG or Case Rate: Payment is based on disease specific treatment and care provided for

the illness. This is usually a fixed fee based on coding and documentation.

Global payment: A fixed fee paid for services pre and post disease. Usually seen in

transplant cases for pre and post-surgical care and in perinatal services and post-delivery care

and includes the physician fees.

Pay for Performance: Payment is based on outcomes and efficiency in care delivery.

Usually seen in Centers of Excellence such as cardiology, orthopedic joints, and Core Measure

attainment.

Third Part Administrator: A third party administers performs utilization review and

processing of claims and the group insurance plan holder provides the benefits and funds the

plan.

Utilization Review and Management

Utilization is an essential element of case management. Case Managers are responsible

for verification of level of care, length of stay, monitoring the patient for treatment modalities,

and assuring the hospital is properly reimbursed for care delivered. Most hospitals and health

33

systems use an evidence-based criteria set to validate pre-admissions, admissions, discharges,

and post-discharge levels of care. The goals of utilization management are:

To ensure effective uses of resources through active review

Determine medical necessity and level of care

Define over and under-utilization of services and inefficient use of resources

Coordination of care with the patient’s payer and the attending physician

Facilitation of appropriate, safe and timely discharge planning

Identify patients who may qualify for disease management programs and active case

management post-discharge

Utilization review begins with a thorough review of the patient’s condition prior to

admission if the organization uses pre-admission and pre-certification case managers. It is their

responsibility to pre-screen admissions for level of care for admission, whether the patient has

been pre-certified for inpatient or outpatient or if it is a Medicare patient, whether the procedure

is on the inpatient only list. Pre-screening can be accomplished at this time and identification of

post-discharge services can be discussed with the patient. Documentation of pre-screening with

registration and post-discharge planning should be completed prior to the patient leaving pre-

screening. Alerting the patient to services available in the pre-screening process accelerates the

discharge process and allows the patient to choose from available providers, interview the

provider, and report to the case manager a list of possible choices upon admission and post-

procedure. Written hand-off to the inpatient case manager will assist the inpatient case manager

to continue the conversation with the patient and family, making referrals, and confirming the

post-discharge plan.

34

Inpatient utilization review is completed on all patients and validates the level of care.

Reimbursement is dependent on proper level of care. Available physician advisor services assist

the case manager/utilization reviewer in determining level of care when the documentation or the

presenting signs and symptoms and treatment plan are indeterminate or incongruent with the

level of care ordered by the attending physician.

A valid order for level of care is dated, timed, and signed by the attending physician and

is a Condition of Participation under Medicare. Level of care starts at the time the order is

written and authenticated. Observation services begin at the time a proper order is written and

after the first nursing intervention.

Two major enterprises provide evidence-based criteria for hospital to complete utilization

review. McKesson InterQual and Milliman Care Guidelines are considered the leaders in the

field of utilization management and assist the case manager in determining the level of care and

validate treatment modalities and core measures. The usual length of stay is noted for the

disease process and assists the case manager in moving the patient through the system. It

provides talking points with the physician for level of care and provides medical evidence for the

case manager to support the decision for level of care or treatment plans.

Denials should be avoided at all costs. It is a detriment to the health of the organization

and, depending upon the patient’s payer, may cause the patient to personally pay for services.

The patient’s benefits have been violated and misused when denials occur because a case

manager failed to provide the appropriate clinical information either telephonically,

electronically, by fax, or by secure website. It is extremely important a system is in place to

capture reviews on a daily basis and provide the information when requested. For Medicare

35

patients and payers who reimburse on a DRG level, it is imperative tight control be exerted on

the utilization review process assuring the treatment plan is followed and altered as the patient’s

condition changes and plans are in place for post-discharge services. Per Diem payers may

“carve out” or deny days within a patient’s confinement for the provider’s inefficiencies such as

a delay in care or testing or lack of discharge planning. These delays can cost the organization

an increase in the cost per case and the length of stay.

Even if the case manager has done all that can be done to avoid denials, the organization

should have an appeal process in place. If the denial occurs while the patient is still in the

hospital, a peer to peer should occur between the patient’s attending physician and the payer’s

medical director. Actively advocating for the patient at this point may avert a denial and avoid a

delay in payment for the organization. The case manager is advocating for the department, the

patient and the organization. If the peer-to-peer is ineffective, some organizations have

templates for appeal letters and are written immediately upon learning of the denial. Other

organizations write a cover letter and send the entire chart with a written explanation for the

appeal. It is important to assure a timely response to an appeal to mitigate a denial or reverse it

completely.

Medicare appeals are based on the Recovery Auditors’ decision to reverse the level of

care and patient classification and request return payment or make the decision to reimburse at a

lower level of care. The purpose of Recovery Auditors is to examine Medicare claims and

determine whether the level of care is correct and if coding of the health care record is accurate

based on the disease treated and documentation of the plan of care and progression towards

discharge.

36

Medicare patient appeals for discharge are vastly different than appeals for denials for

payment. Medicare patients have the right to appeal a discharge if they feel they are being

discharged too soon or if they are not satisfied with the discharge plan. An appeal to Medicare

begins with notification to the Medicare appeals division usually at the state level and ends when

the decision is made by the Medicare intermediary. If the decision is unfavorable for the patient,

a notice is given indicating financial responsibility begins on noon of the next day following the

decision. A secondary appeal can be completed and can take up to 14 days. During that time

period, the organization is required to provide further information on treatment modalities and

any other information valuable to making an informed decision based on the patient’s request for

a secondary review. During the time the secondary review is pending, the patient is protected

from discharge however, if the decision remains unfavorable, the patient is financially liable

from the time of the first notification after the primary decision.

Medicare IMM, Observation Services and ABN Notifications

Medicare requires notification of level of care to its beneficiaries. After performing a

utilization review of the patient’s medical record and the level of care is confirmed at inpatient,

the attending physician must have a valid inpatient order in the medical record and the Important

Medicare Message must be given to the patient receiving inpatient services within 24-48 hours of

admission. The patient should acknowledge notification of the IMM by a signature on the letter.

A second notification must be given to the patient 4-48 hours prior to discharge and a discussion

of post-discharge services must occur between the patient, family, and the case manager

confirming facilities and providers. The second notification is signed by the patient

acknowledging discharge planning has occurred and discharge will occur barring unforeseen

events.

37

If the patient is to receive observation services, a notification and discussion must occur prior to

the patient receiving services and given the option of being discharged or accessing observation

services. The attending physician should apprise the patient of the risks of leaving without

receiving observation services however this does not negate the patient receiving notification of

observation services. Should the patient access observation services, a discussion concerning co-

pays and non-covered items should occur.

Advanced Beneficiary Notifications are given when the service or admission is not considered

medically necessary and the organization will not be reimbursed. The patient will be financially

liable for the hospital stay or the service. An example of when the notice would be given is if a

physician orders a mammogram on a patient admitted for pneumonia because it is convenient for

the patient or a colonoscopy on a patient admitted for cellulitis because the patient can be

prepped by the nursing staff and it is convenient for the patient. An ABN should also be given if

the patient is admitted for social reasons and there is no indication the admission meets inpatient

or observation services. This protects the organization from misuse of the system and the

organization can then bill the patient for services accessed.

Putting It All Together

It is imperative case managers understand the importance of the role they play and how

the decisions made impact the care both in the hospital and in the community. Careful planning

includes early intervention and planning and involvement in the organization’s financial well-

being. Social Work Case Managers and Nurse Case Managers often experience overlapping

roles in patient care, however the final plan should be the result of collaboration and cooperation

with the patient, family, medical team, and case manager. Only through honest and unbiased

38

communication delivered to the patient from everyone on the team will trust develop between the

patient and the medical team. Without the trust relationship, transitional planning may be

delayed, confusing, frustrating, and unable to sustain a patient post-discharge. Patients become

reluctant to leave the care of an organized medical team fearing the aftercare may not meet the

needs. Frequently, Medicare recipients will request an appeal because of a lack of trust in the

discharge or feeling they need one more day to stay in the hospital to ‘get better’. The case

manager’s ultimate responsibility is to keep communication flowing and provide the consistent

message of discharge and the plans for post-acute care.

A day in the life of a case manager begins with reviewing the patients in her care and

prioritizing the day based on the intricate needs of each of the patients. Complex cases require

extra time and effort evaluating and securing resources. The lack of resources in many areas

places an exceptional burden on the case manager attempting to find safe and appropriate

transitional services. Every day in the life of a case manager is unique and must follow the case

management process. When the case management process if followed appropriately, there are

positive outcomes in every area of care.

Quality of Care Outcomes Using the Case Management Process

When evaluating the quality of care, case managers impact the outcomes by:

Increasing patient and family satisfaction

The medical team becomes actively involved in the discharge planning process and

produces long term positive effects on the patients well-being

Positive matching of services with needs sustaining care in the community

39

Reducing re-admissions

Decreasing the cost of care and the length of stay

Involving palliative care and hospice at the opportune time allowing the patient choice

and the right to make decisions while cognitively able.

Fiscal Outcomes

Cost per case is appropriate following care coordination throughout the hospitalization

Appropriate use of critical care

Reduction in ED visits or using the ED as a primary care venue

Utilization of resources and coordination of benefits is optimized

Coordinating patient’s benefits and private resources optimizing the discharge plan

Payer satisfaction and trust built between payer and provider

Reducing social admission for which there is no or minimal reimbursement

Providing an optimal daily throughput of patients

Advocacy

Attention to detail advocating for the patient maximizing benefits and providing fiscally

sound and sustainable care

Increased quality of life especially at the end of life

Providing sound and reliable education on the disease process and organizing continued

education for patients and families sustaining home and community care

Right to decide to continue care, refuse care, or withdraw care as indicated by an advance

directive or final wishes

Builds trust in the health care system and the medical team

40

Timely and appropriate communication with the same message given to the patient by the

entire medical team

Options for care discussed openly and without bias

Case Managers have many duties, tasks, and responsibilities but no particular one is more

important than the patients and families we serve. Patient-centered care is why we are case

managers and why all disciplines, services, and teams depend on our level of expertise to propel

the patient through the system with positive and sustainable outcomes. That is why many of you

are preparing for your certification to assure the groups you are working with you that you are a

patient advocate and an essential and indispensable team member.

Notes

41