This article was recently posted by Glenn Kraus on HCPRO's CASE MANGEMENT WEEKLY. With his permission, it is essential reading for HCM leaders. It highlights the reasons why the UR function can no longer be an 'add on' activity to the hospital case managers' role. Executives lax attention to the issues surrounding 'medical necessity' is no longer realistic if the hospital wants to financially thrive.
Designing and executing a clinical resource management program is not easy. It’s not so much that any one part of the program is difficult to design and implement. Rather, it’s the combination of all the parts that becomes untenable.
When we started this newsletter back in 1994, we reported the difficulties in obtaining information about payer denials. Hospitals simply could not provide actionable information to identify the source of their denials...
When case management was introduced in hospitals in the mid 80s, it was accompanied by a promise to control costs at the bedside.
Announces Intent to Delay ICD-10 Compliance Date
As part of President Obama’s commitment to reducing regulatory burden, Health and Human Services Secretary Kathleen G. Sebelius today announced that HHS will initiate a process to postpone the date by which certain health care entities have to comply with International Classification of Diseases, 10th Edition diagnosis and procedure codes (ICD-10).
The final rule adopting ICD-10 as a standard was published in January 2009 and set a compliance date of October 1, 2013 – a delay of two years from the compliance date initially specified in the 2008 proposed rule. HHS will announce a new compliance date moving forward.
“ICD-10 codes are important to many positive improvements in our health care system,” said HHS Secretary Kathleen Sebelius. “We have heard from many in the provider community who have concerns about the administrative burdens they face in the years ahead. We are committing to work with the provider community to reexamine the pace at which HHS and the nation implement these important improvements to our health care system.”
ICD-10 codes provide more robust and specific data that will help improve patient care and enable the exchange of our health care data with that of the rest of the world that has long been using ICD-10. Entities covered under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) will be required to use the ICD-10 diagnostic and procedure codes.
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Welcome to the March issue of REFLECTIONS which includes some thoughts about defining hospital case management in terms of utilization review. Its time to change the conversation and return to case management practice. We also call your attention to the 2012 OIG work plan which will review observation patterns and the recent change in how active monitoring hours can be streamlined. As always, we welcome your comments and thoughts.

The Leader's Guide to Hospital Case Management
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Deonna Villegas-McPetersCommunity Regional Medical CenterFresno, CA