case management, CMS, HINN, HAC, Medicare, OIG, POA, ABN



  1. Daniels, Stefani MSNA, RN, ACM, CMAC
  2. Ramey, Marianne RN, ACM, CPUR


Purpose/objectives: Compliance with the various Centers for Medicare & Medicaid Services rules and regulations is rapidly becoming a challenge in hospitals as the frequency and complexity of the new mandates have increased. Although compliance officers may oversee major elements emanating from the regulatory agencies, practical application during routine work activities requires current information and peer-to-peer reinforcement. This article addresses some of the more recent changes-or proposed changes-that may impact hospital case management practice and the case managers' role as patient advocate.


Primary practice setting(s): The settings include acute care hospitals, short-stay hospitals, long-term acute care hospitals, and critical access hospitals.


Findings/conclusions: The more information hospital case managers have about the regulatory changes that affect the hospital, its patients, physicians, and associates, the better they can serve as sources of information, resources, and advocates.


Implications for case management practice


* Direct interactions between the case manager and the physician are the best opportunities to share information.


* Influencing medical documentation at the point of service will be dependent upon the case managers' ability to link documentation improvements with benefits for the physician.


* Hospital-Issued Notice of Noncoverage letters are tools that warrant the case managers' attention to protect the patient and the hospital against financial risk.