This workbook reflects a number of important regulatory changes that have occurred in the past 13 years, as well as the new landscape of healthcare reform. It serves as an important resource for case managers, administrators, physicians and others who play a role in the case management process.
Table of Contents
Who Is Responsible for Case Management?
What Is Uncompensated Care?
Moving the Patient in a Timely Manner
The Use of the Emergency Department
The Essence of Effective Case Management
Case Management Is Truly Everyone’s Responsibility
Aligning Incentives: Current Payment Structure
The Physician Payment
Post Acute Venue Payments
Fraud and Abuse
Recovery Audit Contractors Audits
Future Payment Structure
Bundling Physician and Hospital Payments
Post Acute Care Bundling Plan
Post Acute Care Bundling Proposal Details
The Watershed Years of the American Healthcare Delivery System
The Watershed Years
The Barrier Defined
Healthcare Reform: 2010—A Major Watershed Year
Key Obstacles in Reducing Length of Stay
Cajoling Can No Longer Be the Primary Methodology for Dealing with Physicians
The Largest Obstacle
A Preference for the Intensive Care Unit
The Consulting Physician
The Attending Physician in the Role of Quarterback
How to Deal with a Difficult Physician
Obstacle: Physical Plant
Obstacle: Monitoring Equipment
Obstacle: We Wait and Wait for Approval
Obstacle: Staffing Shortage
Is the Postacute Venue Ready
Slow Down, You’re Moving Too Fast
Opportunities for Effective Use of Post Acute Venues
Centralized Case Management System
The Post Acute Venues and Their Roles in the Continuum
Introduction: The Post Acute Venues
Long-Term Acute Care Hospital
New Rules for 2010
Good News for LTACHs
Length of Stay
Benefits and Conditions
LTACH Payment Structure
Comprehensive Inpatient Rehabilitation Hospital/Unit
New Coverage Criteria
Criteria for Admission
60 Percent Rule (Previously the 75 Percent Rule)
Medical Directorship—20 Hours Per Week Rule
Product Line Specialization
Inpatient Rehabilitation—Payment Structure
Skilled Nursing Facility/Unit
Final Rules for 2010
Skilled Nursing Physician Care
Skilled Nursing Payment Structure
The difference between Comprehensive Inpatient
Rehab and Skilled Nursing
Outpatient Rehabilitation and Home Health
Case Management at the Epicenter of an Integrated Health System
The Epicenter of an Integrated Health System
The Hybrid Model of Case Management
Appropriate Movement of the Patient
Diagnosis-Related Group Review
Major Diagnostic Category
Diagnosis Related Groups
With or Without MCC and CC
Projecting the DRG
The Sticky Note
Assigning a Different DRG
Efficacy of Data
Electronic Medical Record
Exercise 1: Develop a Venue Inventory Worksheet
Exercise 2: Identify the Parameters of Case Management in Your Organization
Exercise 3: Key Obstacles
Exercise 4: Opportunities for Effective Use of Post Acute Venues of Care
Exercise 5: Case Management in a Multivenue Setting
Acronyms and Abbreviations
Cherilyn G. Murer, JD, CRA, Founder, President, and Chief Executive Officer of the Murer Group, has long been an active voice in the advancement of quality, cost-effective healthcare. Ms. Murer received a juris doctor degree with honors from Northern Illinois University (NIU) and has coupled her background in law with her previous operational experience as the Director of Rehabilitation Medicine at Northwestern Memorial Hospital, Chicago, Illinois. Ms. Murer is a sought-after lecturer and educator whose focus is on assisting her clients navigate through the complex regulatory, strategic, and financial issues facing healthcare today.
In May 2005, Ms. Murer received a gubernatorial appointment, with Senate confirmation, to a six-year term on the Northern Illinois University Board of Trustees. In 2007, Ms. Murer was elected Chairman of the Board of this state university with over 26,000 students. Ms. Murer and her husband, Michael, have provided a philanthropic gift to NIU to establish the Murer Initiative as a forum for scholarly discussion, policy analysis and cross-disciplinary integration of medicine, law, technology, and finance. In September 2007, Ms. Murer was selected by the university to present the first Annual Executive Speaker Series Presentation, "Conversation with a CEO," co-sponsored by NIU College of Engineering and College of Business. In 2002, Ms. Murer was appointed to the Northern Illinois University Law School’s prestigious Board of Visitors and was honored with its 2003 College of Law Distinguished Alumni Award. Ms. Murer holds an appointment to the faculty of the University of Illinois at Chicago College of Medicine as a Clinical Assistant Professor of Law in the Department of Family Medicine.
Coinciding with the firm’s 25th anniversary (February 2010), Ms. Murer was honored by both the University of Illinois at Chicago and Northern Illinois University. On February 25, 2010, she was inducted into the prestigious Chicago Entrepreneurship Hall of Fame. In April she received the 2010 Northern Illinois University Distinguished Alumni of the Year Award, the highest award given by the NIU Alumni Association to one individual each year who has achieved national, regional, or statewide prominence.
Ms. Murer was pleased to accept, in October 2004, an invitation from the Commission on Accreditation of Rehabilitation Facilities (CARF) to participate in an International Advisory Committee on the development of the first set of International Stroke Rehabilitation Standards. Ms. Murer has presented the keynote address at the Annual Case Management Society of America Convention in Anaheim, California. As a featured speaker, she highlighted the critical role of case management in a reformed healthcare environment. Ms. Murer has been appointed by CARF to its International Advisory Committee to promote globalization of accreditation standards.
Ms. Murer has co-authored with Lyndean Lenhoff Brick and Michael A. Murer four books published by McGraw-Hill. The Case Management Sourcebook is a 300-page text that serves as a guide to designing and implementing a centralized case management system. A second book, published by McGraw Hill and co-published by HFMA, entitled Post Acute Care Reimbursement Manual: A Financial and Legal Guide, addressed the financial impact to post acute venues pre- and post-Balanced Budget Act (BBA). A third book, Compliance Audits and Plans for Healthcare, was one of the first books to address complex heathcare compliance issues.
A fourth book, Healthcare Records Management is an 800-page complete guide to disclosure, retention, and technology. A fifth book was published in April of 2003 by Commerce Clearing House, Inc. (CCH), entitled Understanding Provider-Based Status.
As commencement speaker at her alma mater, Marymount University in Arlington, Virginia, Ms. Murer was awarded the Mother Gerard Phelan Gold Medal; previous recipients have included Nancy Reagan, the Honorable Clare Boothe Luce, Elinor Guggenheimer, and past U.S. Surgeon General, Dr. Antonia Novello. Ms. Murer was also honored by American Express; recognized for her leadership and outstanding accomplishments. American Express described Ms. Murer as "a healthcare pioneer who has been a leader in helping healthcare providers find cost effective procedures without reducing the quality of care."
From April 2004 to June 2008, Ms. Murer was President of the Board of Managers of Oak Tree Hospital at Baptist Regional Medical Center in Corbin, Kentucky. She was Vice President of the Corbin Long Term Acute Care Venture, LLC Board, for the same period of time. She also served on like Boards in the same positions for Oak Tree Hospital at Baptist Northeast in LaGrange, Kentucky, and on the Northeast Joint Venture, LLC Board, from June 2006 to September 2009.
In March 2005, Ms. Murer was featured on the cover of Modern Healthcare Magazine with a lead story on the need for national standardization of Medicare regulations. Ms. Murer has been a columnist for Rehab Management Magazine since 1993. Her column "Issues and Trends" focuses on timely and sometimes controversial subjects impacting the delivery of healthcare. Ms. Murer has authored over 160 articles published in journals and magazines on healthcare finance, regulatory compliance, new business development, and globalization.
Ms. Murer has developed specialized expertise in proton therapy serving as Chair of the Northern Illinois Proton Therapy and Research Center; a project in conjunction with Fermilab and Argonne National Laboratory. Her concern for the future direction of healthcare within our country prompted her to accept an appointment by Vice President George Bush to serve as National Co-Chair, Disability Coalition. She was subsequently appointed as President Bush’s National Co-Chair "Access to Opportunity Committee" and served as a member of the U.S. International Cultural and Trade Center Commission Advisory Committee on Foreign Language Needs of Business.
Michael A. Murer, JD, is Executive Vice President and General Counsel for the Murer Group. Mr. Murer received his juris doctor degree from Georgetown University Law Center in Washington, D.C. and earned his Bachelor of Arts degree in European History at Purdue University in West Lafayette, Indiana.
Mr. Murer’s area of expertise includes interfacing healthcare management with the changing regulatory environment. He has written and lectured extensively in the areas of compliance, electronic medical records, e-commerce, safe harbors, fraud and abuse, the Stark Laws and the structuring of joint ventures and HIPAA. Some of his lectures include "AdvancingTechnology and the Medical Record" at the Healthcare Informatics Expo and Conference in Chicago, Illinois; "HIPAA and E-Commerce" at the Healthcare Financial Management Association (HFMA) Annual Conference in San Antonio, Texas; "HIPAA Mapping and Plotting," for the Illinois Association of Health Plans/RX 2000 Institute in Chicago, Illinois; and most recently "How to Train Your Staff on HIPAA Privacy," for Eli Research teleconference.
Mr. Murer has been a member of the Legal Work Group for Health Information Security & Privacy Collaboration (HISPC)–Illinois II since 2007. This group worked on developing a model uniform patient Electronic Health Record (EHR)/Health Information Exchange (HIE) consent form for possible use by the state-level HIE, clinicians, healthcare facilities and other providers. The Legal Work Group was also tasked with the development of a plan to disseminate the consent form and encourage its use. In July 2009, the group was absorbed by the Illinois Health Information Exchange Advisory Committee.
Mr. Murer served as Assistant Treasurer/Secretary on the Boards of Managers for two Long Term Acute Care Hospitals in Kentucky, as well as each hospital’s Joint Venture Board. From April 2004 to June 2006, he served in these positions for Oak Tree Hospital at Baptist Regional Medical Center as well as the Corbin Long Term Acute Care Venture, LLC. He was also appointed to the same positions for Oak Tree Hospital at Baptist Northeast in LaGrange, Kentucky, as well as serving on that hospital’s Northeast Joint Venture, LLC Board of Managers from June 2006 to September 2009.
Mr. Murer has also served as Executive Vice President of International Healthcare Recruiting, a venture with the University of Utrecht, The Free University of Louvain and other Dutch, Belgian, and Swiss Universities in addressing international recruitment and placement of physical therapists.
Mr. Murer has been a practicing attorney for over thirty-two years and has held faculty appointments at both the graduate and undergraduate levels at Lewis University, Lockport, Illinois and the Graduate Program of St. Francis College in Health Administration in Joliet, Illinois. He was also the 1982 Congressional candidate for the U.S. Congress from the 4th Illinois District.
Mr. Murer has written numerous articles and white papers regarding the legal implications of Industrial Medicine Programs and several articles detailing the complexity associated with networks and alliances. Some of his articles include: "Embracing System Integration," Continuing Care Magazine; "Old Reg’s Can Hamper New Healthcare Entities," Hospital Rehab Magazine; "Healthcare’s Added Burden: The Legal System Integration in Healthcare Network and Alliances," Hospital Rehab Magazine; "Case Management Challenges in Integrated Health Systems," Continuing Care; and "A.G. (After Globalization)" published in the San Francisco Business Times. Additionally, Mr. Murer served from 1990 to 1992 as editor of Year Magazine, a news magazine examining the upcoming decade of change. One of Mr. Murer’s latest articles, "Compliance Guidance for Nursing Facility Caregivers," was published in CCH Healthcare Compliance Letter. In addition, he recently became a member of the CCH Healthcare Compliance Editorial Advisory Board.
Mr. Murer is a leading advocate of e-commerce and technology. He was the lead developer of ComplianceEdge, an interactive Internet compliance-training program for hospitals and health systems; a product developed by Murer Consultants, Inc., for CCH, Inc., and Ernst & Young. He also worked on an upper management web-based tool developed with Aon Corporation.
Lyndean Lenhoff Brick, JD, is the Senior Vice President with the Murer Group. She received her juris doctor degree from The Ohio State University College of Law. Since that time, she has been actively engaged in Healthcare Law and Management Consulting.
Ms. Brick’s practice is concentrated on healthcare law including Medicare/Medicaid regulation and reimbursement; healthcare compliance; HIPAA compliance; Certificate of Need development and review; corporate restructuring, joint ventures, acquisitions and capital formation; reimbursement review and TEFRA structuring; managed healthcare and regulation; and risk management for healthcare facilities. Ms. Brick has lectured on a variety of health-related topics including Case Management, Provider-Based Regulations; HIPAA; Compliance and CORF development. The Healthcare Financial Management Association (HFMA) honored Ms. Brick with their Annual National Institute’s (ANI) Distinguished Speaker Award in 2002 and 2003. She is nationally recognized for her work and client representation in the field of Medicare and Medicaid rules and regulations. She is the regulatory lead counsel to a national base of clients and has served as the acting CEO of a fourteen-chain hospital system in Texas and Louisiana.
Ms. Brick also consults in the areas of strategic and long-range planning for healthcare providers and regularly advises clients in the assessment and development of joint venture opportunities in the healthcare industry. Additionally, she works on the feasibility of development for alternative sites of care such as Ambulatory Surgery Centers (ASCs) and Independent Diagnostic Testing Facilities (IDTFs).
Ms. Brick additionally has significant experience in assisting providers with emergency disaster preparation and recovery. Ms. Brick works with providers individually to ensure that requisite policies and procedures are implemented and in place in anticipation of emergency disasters to ensure optimal reimbursement potential from Federal and State sources of funding. Based on her experiences with past disasters, most recently Hurricanes Gustav, Ike, Katrina, and Rita, Ms. Brick has gained beneficial insight as to Federal disaster reimbursement processes and what measures need to be taken before, during, and after a disaster occurs to promote a provider’s eligibility for reimbursement.
Ms. Brick also has considerable operational experience in the healthcare industry, having been the contract Administrative Director of a 42-bed inpatient rehabilitation unit in Johnson City, Tennessee, and Contract Manager of program development for a 175,000-square-foot outpatient healthcare facility in Canada. In June 2005, Ms. Brick received a gubernatorial appointment to serve as a member of the Illinois Hospital Licensing Board and has since been elected the Board’s Chairperson. Ms. Brick was appointed as one of two members of the board representing governing bodies of hospitals. She serves on the Regional Board of Provena Saint Joseph Medical Center Board of Directors in Joliet, Illinois and is the Finance Chair of the hospital and became the secretary of the Provena adivisional Board in 2009. Ms. Brick also was appointed by Will County Executive Larry Walsh to the Will County Health Department Board.
She has contributed to such healthcare newsletters as Eli Research and CCH Healthcare Compliance Letter. One of her most recent articles for the CCH Healthcare Compliance Letter was titled "Independent Diagnostic Testing Facilities (IDTFs): A Good Way to Cooperate."
Prior to joining Murer Consultants, Inc. Ms. Brick worked as an international attorney with a particular expertise in German. As a business consultant in Chicago, Illinois, her responsibilities included the negotiation and formation of international healthcare joint ventures, medical product development, international marketing and market research, commercial and regulatory law, and capital formation.
Ms. Brick has considerable experience in the formation and operation of foreign-based healthcare clinics as well as in guiding international clients through marketing and the American regulatory process.