Part One: Case Management Boot Camp 2026: Fundamentals for Everyday Practice (ODPTW6013)-Case Management Boot Camp 2026, Part One Presentation

Case Management Boot Camp 2026, Part One Presentation

Pdf Summary

This Module 1 “Case Management Boot Camp 2026” overview explains why hospital case managers must understand reimbursement and evolving payment models in acute care. Case management supports both patient advocacy and employer goals by improving outcomes while reducing costs, denials, readmissions, and avoidable length of stay (LOS)—all of which affect payment.<br /><br />The document frames U.S. healthcare as high-spending with comparatively worse outcomes (high chronic disease burden, preventable hospitalizations, avoidable deaths), noting large national spending on hospital care and significant waste. It defines case management through CMSA, NASW, and ACMA as a collaborative, coordinated process of assessment, planning, facilitation, monitoring, and advocacy across a continuum of care.<br /><br />A major focus is Medicare and Medicaid basics and how inpatient hospitals are paid under Medicare’s Prospective Payment System using DRGs/MS-DRGs. DRGs group clinically similar patients with expected resource use; each DRG has a relative weight that drives a “lump sum” payment after discharge, adjusted by hospital and geographic factors. Documentation and accurate ICD-10 coding are emphasized because they determine DRG assignment, severity (CC/MCC), case mix index (CMI), public reporting measures, and ultimately reimbursement.<br /><br />LOS is presented as a key efficiency and quality metric (publicly reported and tied to value-based purchasing). Expected LOS is determined post-discharge via DRG and coding; actual LOS is influenced by acuity, comorbidities, staffing, practice patterns, patient flow, discharge planning effectiveness, and post-acute care availability.<br /><br />The module reviews managed care tools (preauthorization, utilization review) and common products (PPO, HDHP, HMO, POS), plus Medicare Advantage benefits. It then highlights modern payment approaches—bundled payments (e.g., CCJR, TEAM model), ACOs (including REACH), and Medicare Value-Based Purchasing and Readmissions Reduction penalties—underscoring that hospitals are increasingly accountable for cost and quality beyond discharge. Case management is positioned as essential to coordinating safe transitions and achieving cost-effective, compliant care.

Keywords

case management

reimbursement

Medicare Prospective Payment System

DRG

MS-DRG

ICD-10 coding

length of stay

managed care

value-based purchasing

readmissions reduction