At the American Case Management Association (ACMA) Leadership and Physician Advisor Conference, a question was posed to the speakers from an audience member: “My healthcare organization is pushing us to get patients out of the hospital to improve length of stay, and CMS (the Centers for Medicare & Medicaid Services) requires us to provide quality ratings for post-acute services. What do you recommend when all the top-quality facilities are full, and the only one accepting patients is a low-rated facility?” The person went on to add, “I feel like a salesperson.”
As I sat in the audience struggling not to chime in, I couldn’t help but empathize with the concern of this case manager. Although there is nothing wrong with a career in sales, it can be morally distressing for the case manager, who is under pressure to transition the patient out of the hospital when medically ready, but potentially unable to do so because the options available are places you would not even consider sending your own family members. Knowing enough about some of these facilities, should you try to convince your patient that a poorly rated or recently cited facility is a good idea when you know otherwise?
Many of our colleagues discuss the ethical dilemmas case managers face, but Dr. Ellen Fink-Samnick’s recent book, “The Ethical Case Manager: Tools & Tactics (2023),” eloquently addresses these issues. The ethical considerations in this scenario are non-maleficence (do no harm) and beneficence (acting in the patient’s best interest). These principles are supported by the Conditions of Participation for Discharge Planning (42 CFR §482.43), which require patients to receive quality information about their post-acute options and be included in the treatment planning and decision processes, ensuring autonomy.
The answer to this question involves not straying from our ethical responsibility, as these occurrences do not typically arise often, and there are many other ways to impact the bottom line without causing further harm to our patients. Instead, we should lean into our primary ethical responsibility as case managers – advocating for our patients.
So, what should we actually do in this situation? Since this is not an easy one, I thought I would offer some options for consideration; however, there are likely more options, which warrant internal discussions in your healthcare organization.
I would recommend having an understanding of the top nearby facilities and their bed availability: are we talking weeks, or do they have an opening the next day? Technology can often help answer this question. Then I would recommend having an honest discussion with the patient and their family about the available choices. Inform them if their top choice does not have an available bed, and ask for their input. If the patient remains reluctant to be discharged to any of the available facilities, consult with the care team, including the attending physician and physician advisor, regarding the patient’s concerns, weighing in the ethical and financial considerations of bed availability and use of hospital resources. For Medicare patients, this may be an appropriate time to facilitate the discharge appeal process, if the patient is interested, which may also provide more time for a bed opening for their preferred facility, while the hospital awaits the Quality Improvement Organization (QIO) decision. I would also recommend continued discussions with the care team to continue to “rehab” the patient while they are in the hospital, to further facilitate the progression toward a safe discharge plan. Furthermore, escalate the case to leadership, report the avoidable days attributed to the specific details of the facility, and collaborate with local low-rated facilities to collectively engage in support on how they can improve their standards of care for the community’s benefit. Encourage case management to be forthright with the post-acute facility, explaining the patient’s concerns. Ask for action steps to improve the provision of this information for future patients. Additionally, request a guarantee of the low-rated facility to transfer to the patient’s top choice once a bed opens, if the patient is agreeable to this interim plan. Finally, support the patient in informing their insurance of their limited benefits for quality post-acute services.
EDITOR’S NOTE: The author of this article used artificial intelligence- (AI)-assisted tools in its composition, but all content, analysis, and conclusions were based on the
One of the greatest challenges facing case management today is not a lack of clinical expertise; it is a lack of time. Case managers are
Please log in to your account to comment on this article.
Sepsis sequencing continues to challenge even experienced coding and CDI professionals, with evolving guidelines, documentation gaps, and payer scrutiny driving denials and data inconsistencies. In this webcast, Payal Sinha, MBA, RHIA, CCDS, CDIP, CCS, CCS-P, CCDS-O, CRC, CRCR, provides clear guideline-based strategies to accurately code sepsis, severe sepsis, and septic shock, assign POA indicators, clarify the relationship between infection and organ dysfunction, and align documentation across teams. Attendees will gain practical tools to strengthen audit defensibility, improve first-pass accuracy, support appeal success, reduce denials, and ensure accurate quality reporting, empowering organizations to achieve consistent, compliant sepsis coding outcomes.
Expert presenters Kathy Pride, RHIT, CPC, CCS-P, CPMA, and Brandi Russell, RHIA, CCS, COC, CPMA, break down complex fracture care coding rules, walk through correct modifier application (-25, -57, 54, 55), and clarify sequencing for initial and subsequent encounters. Attendees will gain the practical knowledge needed to submit clean claims, ensure compliance, and stay one step ahead of payer audits in 2026.
Accurately determining the principal diagnosis is critical for compliant billing, appropriate reimbursement, and valid quality reporting — yet it remains one of the most subjective and error-prone areas in inpatient coding. In this expert-led session, Cheryl Ericson, RN, MS, CCDS, CDIP, demystifies the complexities of principal diagnosis assignment, bridging the gap between coding rules and clinical reality. Learn how to strengthen your organization’s coding accuracy, reduce denials, and ensure your documentation supports true medical necessity.
Denials continue to delay reimbursement, increase administrative burden, and threaten financial stability across healthcare organizations. This essential webcast tackles the root causes—rising payer scrutiny, fragmented workflows, inconsistent documentation, and underused analytics—and offers proven, data-driven strategies to prevent and overturn denials. Attendees will gain practical tools to strengthen documentation and coding accuracy, engage clinicians effectively, and leverage predictive analytics and AI to identify risks before they impact revenue. Through real-world case examples and actionable guidance, this session empowers coding, CDI, and revenue cycle professionals to shift from reactive appeals to proactive denial prevention and revenue protection.
Join Ronald Hirsch, MD, FACP, CHCQM for The PEPPER Returns – Risk and Opportunity at Your Fingertips, a practical webcast that demystifies the PEPPER and shows you how to turn complex claims data into actionable insights. Dr. Hirsch will explain how to interpret key measures, identify compliance risks, uncover missed revenue opportunities, and understand new updates in the PEPPER, all to help your organization stay ahead of audits and use this powerful data proactively.
Stay ahead of the 2026-2027 audit surge with “Top 10 Audit Targets for 2026-2027 for Hospitals & Physicians: Protect Your Revenue,” a high-impact webcast led by Michael Calahan, PA, MBA. This concise session gives hospitals and physicians clear insight into the most likely federal audit targets, such as E/M services, split/shared and critical care, observation and admissions, device credits, and Two-Midnight Rule changes, and shows how to tighten documentation, coding, and internal processes to reduce denials, recoupments, and penalties. Attendees walk away with practical best practices to protect revenue, strengthen compliance, and better prepare their teams for inevitable audits.
As AI reshapes healthcare compliance, the risk of biased outputs and opaque decision-making grows. This webcast, led by Frank Cohen, delivers a practical Four-Pillar Governance Framework—Transparency, Accountability, Fairness, and Explainability—to help you govern AI-driven claim auditing with confidence. Learn how to identify and mitigate bias, implement robust human oversight, and document defensible AI review processes that regulators and auditors will accept. Discover concrete remedies, from rotation protocols to uncertainty scoring, and actionable steps to evaluate vendors before contracts are signed. In a regulatory landscape that moves faster than ever, gain the tools to stay compliant, defend your processes, and reduce liability while maintaining operational effectiveness.
Get clear, practical answers to Medicare’s most confusing regulations. Join Dr. Ronald Hirsch as he breaks down real-world compliance challenges and shares guidance your team can apply right away.
Prepare for the 2025 CMS IPPS Final Rule with ICD10monitor’s IPPSPalooza! Click HERE to learn more
Get 15% OFF on all educational webcasts at ICD10monitor with code JULYFOURTH24 until July 4, 2024—start learning today!
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 1 with code CYBER25
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
