Joseph Romano Law

Home Healthcare Association

Thursday, February 17, 2000

The Case Manager must be aware of managed care initiatives to provide cost effective services within the benefit plans. Which of these initiatives are driven by the desire for successful clinical outcomes, and which are primarily driven by the desire for successful bottom line management of the managed care organization? How can one differentiate between the two motivating factors?

During this presentation, the case manager will be presented with guidelines to use in the analysis of each treatment/practice guideline as related to their individual patient or patient populations. In addition, the case manager will be introduced to strategies to aid in the negotiations and/or appeals process. This will help ensure that each patient receives quality services and acheives the best clinical outcomes, while ensuring financial responsibility, thus establishing a win-win situation.

At the conclusion of this offering, the participant will be able to:

Define pros and cons of treatment or practice guidelines for the patient, the provider and the payer.
Appraise problems related to treatment/practice guidelines.
Examine aggressive managed care practices used to enforce treatment/practice guidelines.
Identify three weapons that can be used to defeat restrictive treatment/practice guidelines.

Treatment or Practice Guidelines: Recovery Recommendations or Treatment Barriers?
1. What are treatment/practice guidelines?
2. Purpose
3. Pros and Cons
  1. Providing estimates of optimal recovery
  2. Predicting complications a patient may experience
  3. Limits flexibility of treating professionals
  4. Recovery recommendations vs. treatment barriers
Examples of Restrictive Guidelines
1. Unfair and unnecessary medical documentation
2. Overly restrictive guidelines: i.e. requesting unrealistic progress before acceptance into a TBI/coma stimulation/coma awareness program
Problems with Treatment or Practice Guidelines
1. The guidelines are published by health care management agencies, and vary from company to company
2. The guidelines are written so they are open to HMO Interpretation
3. HMO guidelines are not provided to the insured, the insured's treating doctor or other health care professionals
4. Insurance companies modify the guidelines or restrict the guidelines according to their business needs
5. Guidelines adopted by HMOs vary significantly from insurance plan to insurance plan
Aggressive Managed Care Practices to Enforce Treatment or Practice Guidelines
1. Peer review
2. Precertification and the appellate process
3. Roadblocks to deny or limit coverage
4. Referral or no referral to a specialist in the HMO system/non-participating facilities
5. Release of medical information: Are patients at risk?
Weapons to Defeat Restrictive Treatment/Practice Guidelines
1. Appeals
2. External reviews
3. Bad Faith
4. Suits and Legislation
Novel Funding Approaches to Identify Short-Term and Long-Term Rehabilitation Benefits