Case managers could be at risk relative to discharge planning.
While not significantly common, hospital case managers have been named in nursing malpractice suits, primarily in association with discharge planning.
Attorneys Jessica L. Gustafson, Esq. and Abby Pendleton, Esq. from The Health Law Partners, P.C. discussed this issue and other legal risks case managers can encounter at the Case Management Society of America’s (CMSA’s) 29th Annual Conference and Expo, which took place recently in Las Vegas.
Complaints associated with discharge planning can involve allegations that the patient was discharged before they were medically stable enough to leave the hospital, or that services or supplies required in the outpatient setting were not provided. Ultimately, most cases against case managers are dismissed. These dismissals are usually the result of comprehensive documentation by the case manager, not only involving the plan of care throughout the course of the patient’s hospitalization, but also specific reasoning for the medical decision-making that initiated the plan of care. Additionally, documenting specific conversations with the patient, family members, and the rest of the care team is imperative to capture the dynamic nature of the evolution of the plan of care.
Another area of risk for case managers involves the Health Insurance Portability and Accountability Act (HIPAA). According to Pendleton, “when it comes to HIPAA and case managers, it really boils down to common sense.”
Even though HIPAA has been around for 23 years, the Office for Civil Rights (OCR) pursuits of enforcement have increased significantly in the last decade. This is because in 2009, an obligation was set into place for individuals to report internally if protected health information (PHI) was inadvertently shared with the wrong person or place. Each facility has an obligation to take specific mitigation and investigatory steps to investigate each incident, determining if there is a need to notify the patient, media, or OCR. In general, most prosecutions involving HIPAA center on cases in which PHI was intentionally sold for profit or other gains, as opposed to situations involving unintentional disclosure of information.
One session attendee recounted a situation in which a rehabilitation facility patient was utilizing an Amazon Alexa device in their room. The concern expressed was that technically, the device is always recording. So, discussions about the patient’s medical condition between the patient and the care team were, in theory, being sent to who-knows-where in the Amazon cloud. Gustafson and Pendleton remarked that if the patient is the one bringing in the device and they are aware (supported by signed documentation) that there could be an issue with privacy, for which the facility is not liable, the facility should be covered. However, it was emphasized that this type of situation should not be allowed in the case of an individual sharing a room with another patient.
Cases involving the federal Anti-Kickback Statute typically center on healthcare transactions not usually encountered by case managers. But Gustafson and Pendleton explained the basic concepts, which all case managers should understand. Generally, it is illegal to knowingly offer to pay directly or indirectly in cash or gifts, be involved in a trade of goods or services, or offer free or discounted services in exchange for referring patients for care or services. It is also, of course, illegal to accept cash or gifts in exchange for the referral of patients.
In other words, this statute applies to the individual who pays the kickback, in addition to the individual who accepts the kickback. This can include anyone involved with the patient or the patient’s care, including the case manager. For example, if a case manager has the responsibility of referring patients to Skilled Nursing Facilities (SNFs), hospice, or home health for their continued care, post-hospitalization, and they are paid by a facility or agency to direct more patients there, both the facility/agency and case manager are in violation of the statute.
“There could be 20 legitimate reasons for making a specific recommendation,” Gustafson said, “but if one is to receive goods or services or payment, it’s a kickback.”
October is National Dental Hygiene Month, a great time to take a look at dental coding. For coders who assign ICD-10 codes, our first thought
Among the many responsibilities of hospital case managers, none is more critical or more impactful than the initial discharge planning evaluation. Often referred to as
Please log in to your account to comment on this article.
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.
Sepsis remains one of the most frequently denied and contested diagnoses, creating costly revenue loss and compliance risks. In this webcast, Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, provides practical, real-world strategies to align documentation with coding guidelines, reconcile Sepsis-2 and Sepsis-3 definitions, and apply compliant queries. You’ll learn how to identify and address documentation gaps, strengthen provider engagement, and defend diagnoses against payer scrutiny—equipping you to protect reimbursement, improve SOI/ROM capture, and reduce audit vulnerability in this high-risk area.
Only ICD10monitor delivers what you need: updates on must-know changes associated with the FY26 IPPS, including new ICD-10-CM/PCS codes, CCs/MCCs, and MS-DRGs, plus insights, analysis and answers to your questions from two of the country’s most respected subject matter experts.
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.
Federal auditors are zeroing in on Inpatient Rehabilitation Facility (IRF) and hospital rehab unit services, with OIG and CERT audits leading to millions in penalties—often due to documentation and administrative errors, not quality of care. Join compliance expert Michael Calahan, PA, MBA, to learn the five clinical “pillars” of IRF-PPS admissions, key documentation requirements, and real-life case lessons to help protect your revenue.
During this essential RACmonitor webcast Michael Calahan, PA, MBA Certified Compliance Officer, will clarify the rules, dispel common misconceptions, and equip you with practical strategies to code, document, and bill high-risk split/shared, incident-to & critical care E/M services with confidence. Don’t let audit risks or revenue losses catch your organization off guard — learn exactly what federal auditors are looking for and how to ensure your documentation and reporting stand up to scrutiny.
Learn how to navigate the proposed elimination of the Inpatient-Only list. Gain strategies to assess admission status, avoid denials, protect compliance, and address impacts across Medicare and non-Medicare payors. Essential insights for hospitals.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
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
