Hospital Case Management Advisor - 2015 Article Archive

2015 Articles
by Phoenix Medical Management, Inc.

The articles on this page were published by us throughout 2015. As with all our written work, we welcome your thoughts or critique. Feel free to send an email to

Martin Shkreli

The Bad Boy of Turing

Turing Pharmaceuaticals' CEO Martin Shkreli,raised the price of the life-saving drug Daraprim from $13.50 to $750 per pill. Daraprim is used to treat toxoplasmosis, a condition which can prove deadly for the unborn children of pregnant women and for immunocompromised individuals like AIDS or cancer patients. These vulnerable populations will now have to pay over 5,000% more for their treatment. [...]

Care manager and patient

Who Needs A Hospital Care Manager?

The professional practice of hospital case management is a collaborative process between the patient, the physician, and members of the clinical team to pro-actively influence and advocate for a safe, cost efficient, clinically effective progression-of-care through the acute episode of care and into the community. The question is: Which patient would benefit most from this service? [...]

Lamkin image

Payer Contracting - Part of Revenue Cycle Integrity

Payer contracts are typically silent about UR requirements. The contract refers the provider to the manual which, in essence states that the hospital 'will cooperate' with the payer's UR processes. And that means when they ask you to jump, you will cooperate and ask 'how high.' The only way to remedy this imbalance is to negotiate utilization review language that creates a win-win situation for [...]

doctor and care manager negotiating

Persuasion is The Language of Care Manager Success

Advocacy is the hospital care manager's primary ethical obligation. As the patient moves through the episode of care, the care manager must be able to facilitate timely delivery of care, they must make sure the care is appropriate to the patients reason for admission and their personal preferences, and they must intervene when care or services may not be in the patient's best interest. [...]

care management continuum of care

A Brief History Lesson

This article is actually a letter sent to M.A. Biosiani and C.Y. Jurgens, authors of an article that appeared in Lippincott's Professional Case Management 2015 July-Aug;20(4). 188-97. [...]

Hospital case manager

Data-Driven Case Managegment: An Important Part of Population Health

Achieving value-based care is nearly impossible without an effective case management program. As we approach the 2015 National Case Management Week, October 11-17, please take time to learn more and embrace the contribution of case management. [...]

knee replacement

The Case Manager and Mandatory Bundles

The Comprehensive Care for Joint Replacement (CCJR) may be the first mandatory bundle proposed by CMS, but it won't be the last in the industry's move from fee-for-service to fee-for-value. A robust care coordination program that begins in the hospital and extends through-out the continuum will quickly become a best practice. [...]

point of service medical necessity

2016 OPPS Rule Moratorium Update

The RAC moratorium expires on Sept 30 and will not be extended. Rather, as part of the proposed 2016 OPPS rule, the CMS announced that the QIOs will be doing the reviews. [...]

Medical apparatus

Lessons From Near Misses

A near miss collision in aviation would have made front page news and sparked a wide investigation. Paul Levy asks why isn't the same investigation conducted when hospitalized patients experience a smiliar 'near miss.' [...]

ICD10 coding specificity

ICD-10-CM No Turning Back

Over 25 countries already adopted ICD-10 to classify diseases and related health problems because of the many benefits it provides in the provision of patient care and collection of data. ICD-10 will also improve quality of care and its documentation. (Portions of this article appeared in Health Data Management) [...]

revenue cycle and the URS

Medical Necessity and the Revenue Cycle

Too often, the scope of the utilization review specialist is on the application of InterQual or MCG guidelines and whether the available medical documentation reflects those guidelines. If the documentation does, the assumption is made that the patient is eligible for hospital admission. Unfortunately, that is not always the case. [...]

Old lady in hospital bed

Does My Mother Really Need That Central Line?

Congratulations to Dr. Anton Travis Manasco, PGY2, and Dr. Judy Linden, Associate Professor of Emergency Medicine and Vice Chair for Education, for their publication in the JAMA on the role of palliative care in emergency medicine! [...]

Observation Unit Signage at Riverside Medical Center, Kankakee, IL


Congress unanimously approved a bill that requires hospitals across the country to tell Medicare patients when they receive observation care but aren't actually admitted to the facility--a difference that most patients miss until they receive their medical bills. [...]

Pharmacist at bedside

Enhance the Med-Rec Process

Create a multidisciplinary team to identify where your hospital can best improve its medication reconciliation process, including how changes to your electronic health record (EHR) and greater use of pharmacists can make reconciliation a simpler and more effective task. [...]

About Anne Llewelyn

When Life Changes on a Dime

We have all been there--one minute you're fine, and the next, you’re not. In Anne's case, disruption came in the form of a serious medical issue that interrupted her life completely. [...]

case manager and the healthcare team

Predictive Information Helps Hospital Case Managers

The top 5% of patients, ranked by individual health care dollars spent, are responsible for almost half of the nation’s total personal health care dollars spent. Finding and managing care coordination for this group of patients can be an efficient and effective way to increase quality and reduce total costs for the entire hospital population. [...]

home care better than hospital care

Care at Home Less Expensive than Hospital Care

Three years after the start of the Independence at Home project, more than half (53%) of the participating organizations have been given bonuses ranging from $275,000 to $2.9 million for shrinking Medicare costs and improving patient care. [...]


How To Make Sure Patients Understand Health Information

The success of health system reform will depend in large part on the capacity of individuals, families and communities to make informed decisions about their health. Health literacy is lowest among the more vulnerable members of our communities—those with lower education levels, racial/ethnic minorities, the uninsured and publicly insured, and the elderly. [...]

Case Manager and Healthcare Team

Riverside Medical Center Case Management Case Study

When a hospital determines to transform its care management program, it takes more than new job descriptions and work flow activities. It takes a change in culture driven by the executive sponsors to embrace a team philosophy to manage the patients progression of care. This is how Riverside did it. [...]

Turn two plugs into one

UR and CDI - They Go Together

Should CDI and UR continue to be separate roles when both are reviewing the very same documentation? As hospitals are looking for ways to improve efficiencies, it may be time to consider an integrated role. [...]

Observation Unit

Bundled Payment for Observation Care

The FY2016 OPPS proposal includes bundling all observation services. Providers will have to re-think what services are essential to determine the patient's need for acute care hospitalization and to avoid spending more than the anticipated payment of $2011. We urge hospitals and medical staff to rethink the value of evidence based protocols for the high volume observation population. [...]

Directing Admitting Traffic Image

Directing Admitting Traffic

There is no one 'best practice' defining the role of the admitting hospitalist, but there does seem to be some role features that are encountered more than others. [...]

Outpatient costs

MSPB - The New Value Proposition

As part of their advocacy role, the hospital case manager is best positioned to influence physician practice behaviors once hospitals learn to create knowledge out of data. [...]

Transition Planning

A Change in Culture to Improve Discharges

Healthcare reform continues to pick up steam. The changes in reimbursement and the introduction of new incentives bring continued uncertainty and anxiety for healthcare providers, patient and families, and healthcare leaders. Everyone hears that the changes are meant to bring about high quality care at the lowest price. But the question on the minds of everyone is how will this be accomplished? [...]

The Patient Navigator article image

The Patient Navigator

Many compelling organizational issues have recently surfaced making the case for a change in hospital case management purpose and operations. It’s a change in the marketplace that signals a change in the role of the case manager from discharge planner (DCP) and utilization reviewer (UR) to that of THE PATIENT NAVIGATOR to advocate for the patients while helping them navigate the progression the ca [...]

The New Knowledge Worker image

The New Knowledge Worker

Hospital care managers need excellent communication skills, negotiation skills, a basic understanding of the psychology of human behavior, agile and creative thinking skills to handle intricate patient and physician interactions, and knowledge of hospital operations to help the patient navigate through the system and beyond. [...]

Preparing for the Future image

Preparing for the Future

In the often cited science experiment, when a frog is placed in a pot of scalding hot water, it will immediately jump out. But if the water is cool and heat is gradually applied, the frog will stay in the pot until it is ultimately boiled. This experiment underscores the danger of gradual change. [...]

Here We Go Again article

Here We Go Again

"Here we go again." That was one case manager's reaction when she learned that the case management department would be reorganizing itself to move to an 'outcome-oriented' practice model. [...]

DRIP Systems vs Information Systems article image

DRIP Systems vs Information Systems

No matter what information system your hospital uses, it produces data.....lots of data.....more data than you can possibly imagine....and more data than you can probably use. There's only one snag: Hospitals are still having a hard time converting the data into information. We call these facilities DRIP organizations: Data rich, information poor. Without information, hospital executives, depa [...]