Module B: Improving Claims

CE Credits: 1.5


Case managers, with our role as liaison among patients, payers, and the healthcare team, are in a unique position to improve claims and reimbursement, support the revenue cycle, and bridge the gap between the finance and clinical departments. This module explores how CMs engage with the organization’s operating revenue system and various claim issues–such as with Medicare and the Recovery Audit Contractor Program—as well as commercial claims. Then, the module looks at how CMs will likely encounter—and how they can maximize the care for—the uninsured and medically indigent population.

Learning objectives: After completing this module the case manager will be able to:
» Recognize the role of case management within the revenue cycle
» Discuss the importance of managing Medicare claims and reimbursements
» Describe the Medicare Recovery Audit Contractors (RAC) Program
» Discuss the importance of managing commercial claims and reimbursements
» Describe the importance of managing state Medicaid claims and reimbursements
» Identify strategies to lessen the impact of the uninsured and medically indigent

Advance your professional practice: As CMs, we are conduits between patients and the often daunting, frustrating system of insurance claims. When we master the policies and possible pitfalls of that system, we can help our patients navigate it more smoothly.


Improve organizational performance: A healthy revenue cycle is vital to the success of a hospital or health organization as a whole. When all of the transdisciplinary team members understand and support the case management team, and their role in getting claims approved and reimbursed, every team member can benefit, and the hospital will encounter fewer rejected claims and a healthier bottom line.