Module C: External Forces

CE Credits: 2.0


This module details the roles that several external forces—from insurance company plans to regulatory bodies—play in the day-to-day duties of a case manager. First, the module details the payer forces—from the different types of insurance plans to the different models for coverage (such as the patient-centered medical home model and connected health model). Next, the module looks at the regulatory forces that affect coverage and transitions of care (such as HIPPA), as well as the legal forces that can affect discharge planning (such as hospital-acquired infections, as well as issues related to medical identity fraud). Finally, the module details how CMs should differentiate between a governing body’s standards and its regulations.

Learning objectives: After completing this module the case manager will be able to:
» Describe payer forces including Medicare, Medicaid, Tricare and commercial payers
» Discuss regulatory forces including EMTALA, HIPPA, Medicare, Medicaid and the Joint Commission
» Identify legal forces including COBRA and CMS operations
» Recognize the differences between standards and regulations

Advance your professional practice:: The varying issues of insurance coverage and governing bodies can affect patients—and their discharge plans—in wildly different ways. Case managers must be knowledgeable about the complex variables that affect how we navigate the system for our patients and how to avoid gaps in care or other negative outcomes.


Improve organizational performance: Healthcare organizations continue to face increasing pressure to cut costs while also increasing quality. These factors require care teams to have a solid understanding of how to help our patients while also adhering to a variety of legal and regulatory standards.