«Case Managers' Role in Maximizing Reimbursement» - Free Essay Paper

Case Managers' Role in Maximizing Reimbursement

Financial issues are the most significant element of any activity because only justified expenses may lead to prosperity. Moreover, nothing else can stimulate market players to improve the quality of their services but money. The social sphere is not an exception from this tendency, including the healthcare system. Each of its structural elements should function efficiently and justify costs spent on their development. For a long time, the question about the returning of investments in case management had been quite controversial. A few years ago, the situation changed, and case managers gradually proved their efficiency, including financial returns. The paper seeks to explore how they help maximize reimbursement and compare programs funded by the government and the private sector.

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Human health is the primary value of the individual, his or her employer and the whole community where he or she lives. Only a healthy person can work productively and develop the social institution successfully, providing the prosperity and progress of society. That is why, the issue of health care reimbursement takes the leading place among diverse governmental programs, as well as private initiatives. Despite similar purposes, all insurance and reimbursement programs funded by the national system and private investments differ from one another.

If speaking about the government, it is worth to admit that it is the key investor in health care. Having a range of powerful tools for managing the health care market, it certainly plays the role of a regulator. There are a few state agencies providing the implementation of programs funded by the government and aimed at regulating technologies and treatment (Centers for Medicare and Medicaid Services (CMS)), standards of quality and safety (Agency for Healthcare Research and Quality (AHRQ)), and the insurance market (Affordable Care Act (ACA)) (Troy, 2015). Reimbursements are one of the numerous ways to establish rules, encourage the best providers, and punish for the deviation from state standards. Thus, these principles of regulation are integral part any of reimbursement programs funded by the government.

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In its turn the private sector has its specific function and appropriate interests, which it tries to reach by means of compensation programs. Thus, reducing the period of employees’ disability and ensuring their presence at the workplace is one of leading purposes. Because of this, private programs often include a wider range of medical options if comparing to governmental ones. It can be services aimed at the prevention of diseases, psychological assistance to patients and their families, post-traumatic help, and others. In the other words, the private sector is interested in everything that can help avoid a long-term disability and provide fast recovery. It is the reason for including to reimbursement costs for treatment and diagnostics using innovative technologies that differentiate private sector programs from governmental ones that reimburse standard packages. Today the private sector offers workers health programs that include the so-called “integrated options,” implying the combination of medical services (AAOHN, 2013, p. 327).

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Moreover, saving money is an urgent task of both the government and private agencies. State reimbursements programs, like Medicare and Medicaid, require lower costs than the average cost of patients’ serving, and in this case, they are inferior to private programs. However, despite larger financial opportunities, the private sector also strives to focus on cost-containment strategies. Thus, the quality of health care services exceeds their volume for both state and private investors, and this indicator is the primary reason for making a decision on reimbursements.

Regarding this, case managers play a vital role in achieving the best outcomes in improvements in medical services and helping their hospital maximize reimbursements because they often coordinate preventive, actual or post-traumatic treatment (Eramo, 2013). Only a well-coordinated healthcare strategy can help to establish an effective plan of actions and avoid wasting time and resources. The latter is the primary task of case managers. Thus, in addition to providing timely and qualified medical care to make patients’ outcomes better, they promote a high level of health services as well as their cost-effectiveness. Shortening the length of patients’ staying in the hospital is one of the numerous evident contributions to saving hospital’s expenses. It demonstrates case managers’ return on investment (ROI) per case (Daniels & Frater, 2011).

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Moreover, despite case managers do not directly contribute to reimbursement, they work with the health care team to ensure correct coding. It is worth to admit they often succeed better in this issue, and their close cooperation with all participants of the health care industry allows them to operate with the actual practical information about the diversity of existing financial mechanisms, as well as the smallest nuances and differences between them. Close communication with patients at the initial stage of medical care and during the post-hospital period plays a crucial role in minimizing negative moments, such discontent or misunderstanding. Being permanent patients’ navigators, case managers may prevent any organizational problems and timely correct patients’ feedback that finally can help the hospital avoid financial punishment and maximize reimbursement.

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In conclusion, the majority of improvements in the health care system today are related to the work of case managers, whose role has been underestimated for a long time. However, the understanding of their effectiveness has gradually become evident. They ensure that return on investments is directed at the development of nursing case management. Besides their functions of coordinators and navigators, case managers are the key players in reimbursement within both governmental and private programs that obligate them to be aware of all financial nuances, including the ones mentioned above.

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