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

Video Transcription

Video Summary

Dr. Tony Sesta opens a case management webinar series by explaining why reimbursement knowledge is increasingly essential for hospital case managers. She emphasizes the constant balancing act between advocating for patients and supporting organizational financial performance, noting that metrics like length of stay, denials, readmissions, and new payment models affect daily case management work—especially safe, timely transitions across the continuum of care.<br /><br />She frames the discussion within broader U.S. healthcare realities: the U.S. spends far more per capita than peer OECD nations yet often has poorer outcomes (lower life expectancy, higher chronic disease burden, more preventable hospitalizations). This creates urgency for case management to move beyond task-based work toward improving quality and cost outcomes.<br /><br />Sesta reviews key professional definitions of case management (CMSA, NASW, ACMA) and encourages organizations to adopt a clear departmental definition. She then explains Medicare (Parts A, B, C/Medicare Advantage, D), patient cost-sharing, and the importance of understanding benefit rules (e.g., SNF coverage requirements and coinsurance). Medicaid is described as a joint federal-state program covering low-income individuals and funding most long-term custodial nursing home care.<br /><br />A major focus is Medicare’s prospective payment system using DRGs/MS-DRGs, relative weights, base rates, complications/comorbidities, coding accuracy, and case-mix index. She outlines managed care structures (PPO, HMO, POS, high-deductible plans) and newer alternative payment models including bundled payments, value-based purchasing, readmission penalties, and ACOs—highlighting how coordinated discharge planning and post-discharge follow-up are central to success.

Keywords

case management

reimbursement

hospital case managers

Medicare

Medicaid

DRG

MS-DRG

prospective payment system

length of stay

readmissions

bundled payments

value-based purchasing

accountable care organizations

discharge planning

continuum of care