This program will provide a foundation of knowledge and understanding of the Diagnosis Related Groups (DRGs) system used as the structure for reimbursement under the Medicare and Medicaid programs. Included in this will be a review of the DRG relative weights, case mix index and expected lengths of stay. Medical record coding will be explained in the context of how hospitals get reimbursed. This will be followed by a discussion of managed care and managed care contracting as well as the various managed care products currently on the market. The program will conclude with a discussion on bundled payments and what case management professionals need to know in order to assist their organizations in controlling cost and length of stay in a bundled payment environment where patients may access care and use resources at any touch point on the continuum.
After attending the session, participants will be able to:
- Understand DRG Prospective Payment System.
- Review how hospitals get paid using the diagnosis related groups.
- Discuss managed care contracting and how that affects reimbursement.
- Describe the various types of bundled payments.
- Identify the role that case management can play in managing cost.
- Relate the various payment methods to the role of the case manager.
- Review how the Medicare payments change over time and based on the hospital.
Areas Covered in the Session:
- Diagnosis Related Groups (DRG)
- Managed care definition
- Managed care contracting
- Case rate, Per diem and Percentage(%) of Charges contracts
- Managed care products
- Bundled payments – Mandatory and voluntary
- Managing cost across the continuum
- What case managers need to know while educating patients
- Director of Case Management
- RN Case Managers
- Director of Finance
- Director of Social Work
- Social Workers
- Physician Advisors
- Directors of Nursing
About the Presenter:
Toni G. Cesta, Ph.D., RN, FAAN is Partner and Health Care Consultant in Case Management Concepts, LLC, a consulting company which assists institutions in designing, implementing and evaluating acute care and community case management models, provides education on case management and related topics, and on-site assistance to case management departments.
The author of nine books, and a frequently sought after speaker, lecturer and consultant, Dr. Cesta is considered one of the primary thought leaders in the field of case management.
Dr. Cesta writes a monthly column called “Case Management Insider” in the Hospital Case Management journal in which she shares insights and information on current issues and trends in case management.
Prior to her current work as a case management consultant, Dr. Cesta was Senior Vice President – Operational Efficiency and Capacity Management at Lutheran Medical Center in Brooklyn, New York. Prior to her position as Senior Vice President at Lutheran Medical Center, Dr. Cesta has held positions as Corporate Vice President for Patient Flow Optimization at the North Shore-Long Island Jewish Health System and Director of Case Management, Saint Vincents Catholic Medical Centers of New York, in New York City and also designed and implemented a Master’s of Nursing in Case Management Program and Post-Master’s Certificate Program in Case Management at Pace University in Pleasantville, New York. Dr. Cesta completed seven years as a Commissioner for the Commission for Case Manager Certification.
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