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Using hospital-based case management to reduce payer denials.

S Daniels1

  • 1Phoenix Medical Management, Inc., Pompano Beach, FL, USA.

Healthcare Financial Management : Journal of the Healthcare Financial Management Association
|November 11, 1999
PubMed
Summary
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A revised case management program significantly reduced denied insurance claims for avoidable inpatient days. This assertive resource management approach proved more effective than initial functional consolidation efforts.

Area of Science:

  • Healthcare Management
  • Health Services Research
  • Quality Improvement

Background:

  • Peninsula Regional Medical Center faced increasing denied insurance claims.
  • Denied claims were primarily for avoidable, nonacute-care inpatient days.
  • Initial case management strategies proved ineffective.

Purpose of the Study:

  • To implement and evaluate a case management program.
  • To reduce denied insurance claims for nonacute inpatient care.
  • To improve resource management in inpatient care settings.

Main Methods:

  • Initial implementation focused on functional consolidation.
  • A revised program incorporated assertive resource management.
  • Key performance indicators included claim denial rates.

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Main Results:

  • Initial efforts failed to reduce claim denials.
  • The revised program substantially and rapidly decreased claim denials.
  • Assertive resource management demonstrated significant impact.

Conclusions:

  • Assertive resource management is crucial for effective case management.
  • Case management programs require strategic focus on care monitoring.
  • Optimized resource management can reduce healthcare claim denials.