BY PATRICIA RESNIK, MJ, MBA, FACHE, RRT, CPHQ, CHC, CHPC
Introduction
Quality, case management (CM) and utilization management (UM) are key to the financial success of a healthcare organization and play a vital role in the revenue cycle. This article focuses on important connections between quality, CM and UM, and the potential impact on organizational financial outcomes.
UM & Quality in Acute Care
According to the Commission for Case Management Certification (CCMC), utilization management is defined as “management of health services to ensure that when offered they are medically necessary, provided in the most appropriate care setting, and at or above quality standards” (Commission). Utilization review in the acute care setting is covered under the Centers for Medicare and Medicaid Conditions of Participation for Hospitals, requiring hospitals to meet certain requirements, including, but not limited to a “utilization review (UR) plan describing the scope and frequency of reviews of Medicare and Medicaid patients for medical necessity of admissions to the institution, duration of stays, and Professional services furnished, including drugs and biologicals” (Condition). Professional case manager UM registered nurses (UM RN) apply industry-accepted screening criteria to determine whether the documentation in the medical record supports an inpatient admission or outpatient/observation level of care. The medical judgment of the admitting /attending physician supported with detailed clinical documentation is critical for supporting the medical necessity determination for the inpatient admission. Clinical documentation Integrity (CDI) specialists provide added value to the UM process as they review medical records and prompt documentation clarity through concurrent queries, while physician advisors support the UM operations through medical leadership and peer-to-peer physician discussions and education.
Through other regulatory requirements, notably the 2-Midnight Rule, the CMS provides clarity regarding the circumstances for payment of an inpatient admission under Medicare Part A. The Beneficiary and Family Centered Care-Quality Improvement Organizations (BFCC-QIO) audit short-stay claims for the appropriateness of billing in accordance with the two-midnight rule (Center).
Utilization management is highly regulated and ultimately drives the potential quality measures that may be applicable to an acute care episode of care, dependent upon whether the final billing is inpatient or outpatient. The types of quality measures that may apply to the episode of care are based, in part, on the billing status at discharge. These quality measures may financially impact the organization in a positive or negative manner. The potential quality measures include, but are not limited to, measures associated with the CMS Hospital Inpatient Quality Reporting (IQR) program, Hospital Outpatient Quality Reporting (OQR) program, Hospital Readmission Reduction Program (HRRP), Hospital Acquired Conditions (HAC) Reduction Program (HACRP) and the Hospital Value-Based Purchasing Program (VBP) (Association). Additionally, commercial payer contracts are hospital-specific and may also include defined quality measures applicable to the acute care setting, and may also be dependent on the type of claim – inpatient or outpatient. It is imperative for case managers in a discharge planning role or working as a UM registered nurse to gain understanding of the UM, denial and appeal sections of hospital payer contracts to ensure the payer-required UM requirements are followed, and for awareness of any payer-required quality measures that may be included within an episode of care.
CM & Quality in Acute Care
Case managers and social workers (SW) facilitate discharge planning and transitions of care, coordinating post-acute care services and appointments for patients. Discharge planning is also a CMS Condition of Participation, with regulatory required processes surrounding the discharge planning aspects of a patient’s episode of care (Condition: Discharge). The degree to which an acute care case manager remains engaged with a patient post-discharge varies by hospital, yet this transition in care from the acute care setting is crucial to ensuring the patient and family or caregiver has the necessary resources well-coordinated to mitigate the possibility of readmission. Readmissions are part of the CMS Hospital Readmission Reduction Program (HRRP) applicable to patients discharged as an inpatient, a direct connection to both CM and the UM process as well. A hospital’s payment from CMS may be reduced for excess readmissions up to a maximum penalty of 3% (Hospital Readmission Payment).
Patient experience is measured with The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), a “national, standardized publicly reported survey of patients’ perspectives of hospital care” (Hospital). Discharge information and transition to post-hospital care are part of the HCAHPS, and, patient discharge is, in part, a direct responsibility of the case management and social work team. HCAHPS Star Ratings appear on the Care Compare website and are part of the Hospital Value-Based Purchasing (HVBP) program (Fact Sheet). There are five HCAHPS Survey questions related to “Leaving the Hospital,” two of which the case manager or social worker facilitating post-acute care services may directly impact by engaging with the patient and family to fully assess post-acute care needs, set up the post-acute care services in accordance with patient choice and preference and ensure that ordered services actually occur post-discharge (Survey).
Across the Care Continuum
Case managers work in a variety of clinical and non-clinical care settings across the continuum of care, including, but not limited to, Veteran’s Health Administration skilled nursing facilities, inpatient rehabilitation facilities, home health agencies, inpatient psychiatric facilities, Federally Qualified Health Centers, accountable care organizations (ACOs), population health entities and payers. Each setting or entity with quality measures that may be mandated as part of federal quality programs, or may be part of financial risk arrangements between payers and providers. Regardless of the type of setting, the expertise of the case manager should be leveraged to ensure successful achievement of quality measures.
Case managers working in roles with payers may have pivotal roles ensuring Healthcare Effectiveness Data and Information Set (HEDIS) measures are achieved for a defined population of members. Examples of the 2024 HEDIS measures include, but are not limited to, “Blood Pressure Control for Patients with Diabetes,” “Osteoporosis Screening in Older Women,” “Transitions of Care,” and “Follow-up After Emergency Department Visit for People with Multiple High-Risk Chronic Conditions” (HEDIS). As case managers provide support and services to members with chronic health conditions, with proper training, they may also serve as an expert resource for closing quality gaps in care for HEDIS measures.
As of January 1, 2024, there are 480 accountable care organizations participating in the Medicare Shared Savings Program, with 10.8 million Medicare beneficiaries assigned to these ACOs (Fast Facts). An ACO may be eligible to share in the savings it achieves for Medicare when that ACO is successful in delivering high-quality care while reducing the overall cost of care (Shared Savings). Delivering high-quality care is measured through the achievement of defined quality measures for ACOs (Quality Payment). While case managers working in ACO and population health entities focus on coordinating services for members, supporting members on achieving established goals, and providing educational resources to members, with proper training they may also help to address the defined ACO quality measures for the performance year.
Structure Process & Outcome
Creating the operational infrastructure for case management and UM within a healthcare facility or entity is imperative to success and begins with a foundation of, and focus on, quality. Starting with the regulatory requirements that may exist, such as the CMS Conditions of Participation, or the Medicare Shared Savings regulations for ACOs, or requirements as part of a contractual relationship with a payer, the policies, procedures and workflows for case management and UM should be clearly established, reviewed regularly, updated as necessary and include key performance indicators for the department that help to identify ongoing opportunities for improvement, and measures of success.
The foundation of quality includes establishing a clear connection between external regulatory required quality measures and internally established quality measures with the roles and responsibilities of case management and utilization management. Providing ongoing data analysis leveraging dashboards displaying current performance compared to established goals helps to maintain focus on achievement of goals, and identification of potential barriers impeding progress.
Training, Education & Professional Development
Case management and utilization management are highly regulated, requiring ongoing investment in professional development and training of staff to keep abreast of current industry trends, and regulatory changes and updates. Although case managers, UM nurses and social workers may not always view themselves as healthcare quality professionals, there is a clear connection between the work of these professionals and the discipline of quality from the perspective of patient experience, transitions of care and the financial performance of an organization. Investing in the professional training and education of case managers, UM RNs and social workers should include formal training in healthcare quality.
Quality Competency & Training
The National Association for Healthcare Quality,(NAHQ) a national leader in advancing the improvement of healthcare quality and safety, developed The Healthcare Quality Competency Framework© (Framework) to address the need for “a standard, widely accepted, comprehensive definition of the competencies required for healthcare quality” (Workforce Competencies). The twice-validated Competency Framework describes the eight competency domains, 29 competencies and 486 skills statements “required for success in current and future healthcare quality positions” (Competency Framework).
The NAHQ Healthcare Competency Framework© offers a roadmap for healthcare quality training and education for case managers, utilization management RNs and social workers as they continue to play a pivotal role in the success of the financial performance of healthcare organizations and entities.
Summary
There is a clear connection between quality, case management and utilization management, and together, these professional disciplines provide a robust infrastructure for driving successful revenue cycle performance.
Key Actions:
Understand the regulatory requirements for quality, case management and utilization management appropriate for the setting of care, and for each type of payer.
Provide structured onboarding, orientation, and ongoing professional development and competency- based training for UM and CM staff, including the NAHQ Healthcare Competency Framework©.
Embed quality into CM and UM operations through standardized policies, procedures, and workflows, reviewing at scheduled intervals and updating as necessary.
Create a defined set of CM and UM key performance indicators with continuous monitoring methods, and rapid cycle process improvement methodologies to drive outcomes.
References
Commission for Case Manager Certification, Glossary of Terms, (n.d.) Commission for Case Manager Certification (CCMC) (ccmcertification.org)
42 CFR 482.30 Conditions of Participation for Hospitals: Utilization Review: eCFR :: 42 CFR Part 482 — Conditions of Participation for Hospitals
Center for Clinical Standards and Quality/ Quality Improvement and Innovation Group Ref: BFCC-QIO 2-Midnight Claim Review Guideline, March 2022. Center for Clinical Standards and Quality/ Quality Improvement and Innovation Group (cms.gov)
Association of American Medical Colleges, Hospital Payment and Quality, Quality Measures Spreadsheet (updated January 1, 2024) Hospital Payment and Quality | AAMC
42 CFR 482.43 Condition of Participation for Hospitals: Discharge Planning. eCFR :: 42 CFR 482.43 — Condition of participation: Discharge planning.
What is the Hospital Readmission Reduction Program (HRRP). Sept. 2023. Hosp. Readmission Reduction | CMS
Hospital Readmission Reduction Program, Payment Hospital Readmissions Reduction Program (HRRP) Payment (cms.gov)
Hospital Consumer Assessment of Healthcare Providers and Systems, (August 1, 2024). Home (hcahpsonline.org)
Hospital Consumer Assessment of Healthcare Providers and Systems, (August 1, 2024) HCAHPS_Fact_Sheet_2022 (hcahpsonline.org)
HCAPHS Mail Survey, (May 2024). May_2024_DRAFT Survey Instruments_English_Mail (hcahpsonline.org)
HEDIS My 2024, Health Effectiveness Data Information Set, HEDIS MY 2024 Measures and Descriptions (ncqa.org)
Shared Savings Program Fast Facts, (January 1, 2024) (Shared Savings Program Fast Facts – As of January 1, 2024 (cms.gov))
Shared Savings Program. (July 11, 2024) Shared Savings Program | CMS
Quality Payment Program, (Jan 26, 2024) 2024 Medicare CQMs Specifications and Supporting Documents for Accountable Care Organizations Participating in the Medicare Shared Savings Program – QPP (cms.gov)
NAHQ’s Healthcare Quality Framework. Reduce Variability in Healthcare Quality Competencies (2024) Competency Framework | NAHQ
Workforce Competencies for Healthcare Quality Professionals: Leading Quality Driven Healthcare, Journal for Healthcare Quality 41(4):p 259-265, July/August 2019
Patricia Resnik, MJ, MBA, FACHE, RRT, CPHQ, CHC, CHPC, is a senior healthcare executive with extensive experience in healthcare quality, case management, and utilization management across the continuum of care. She is the current president of the board of directors for the National Association for Healthcare Quality, and the executive director, Quality & Revenue Cycle for Medovent Solutions, LLC. Ms. Resnik is a Fellow in the American College of Healthcare Executives and is certified in healthcare quality, compliance, and privacy.
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