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Negotiating for successful outcomes in case management practice
Negotiating for Successful Outcomes in Case Management Practice
Sandra Lowrey, RN, CRRN, CCM
C
ase managers are charged with the important role of trying to effect change to promote best outcomes.
Negotiating for care and cost-effectiveness is a frequent strategy with providers, payers, and clients. The Case Management Society of America’s (CMSA) national standards for case management practice indicate the case manager’s role in negotiating should include the following. TCM 70
January/February 2004
• Advocate and strive to achieve consensus among all parties to promote positive client health and wellness outcomes. When consensus cannot be achieved, the case manager should advocate and facilitate consensus through a review of viable alternatives, while encouraging the health care team to respect client/family choices. • Represent the client’s interests by advocating necessary funding, appropriate treatment, and treatment alternatives and by timely coordinating health services. • Educate and assist in facilitating client/family access to necessary and appropriate health care services. Case managers often find themselves having to “sell” their perspective. Whether negotiating with physicians, other providers, clients, family members, or other payers, we constantly try to
achieve better clinical and financial outcomes through negotiation. It always takes two parties to negotiate, so acquiring skillful negotiating techniques, while understanding where the other party is coming from, is critically important for successful case management. Consider the following case example in which the need for negotiating both care and cost is indicated. The names of both the client and company have been changed. Case Scenario Mr. Foggy, a 72-year-old single man, sustained an embolic stroke 2 months ago and received rehabilitation in a skilled rehab facility. His family was dissatisfied with his care and referred him to a specialized skilled brain injury facility, We Care, for rehab. The medical records and current treatment team describe severe aphasia and cognitive deficits, mild to moderate motor/sensory deficits, and moderate difficulty with balance. We Care is not a Medicare-contracted provider. Mr. Foggy’s secondary health insurer requested an independent case management assessment and recommendations. After reviewing the proposed treatment plan, which included “1 month of physical therapy, occupational therapy, and cognitive therapy 5 times a week supervised by a physiatrist,” the case manager contacted the family, who confirmed the facility’s assessment and explained that their dissatisfaction with the previous facility was based on a decubitus ulcer and inexperienced staff. They reviewed We Care’s proposed plan when they toured the facility and strongly wanted Mr. Foggy there because of the specialized and experienced staff and recommendations from other family members they had met in a support group. We Care was supportive and realistic in terms of outcome and long-term care needs. The case management plan shown in Table 1 includes the recommendations that require negotiation. In Mr. Foggy’s case, the negotiating might go something like this among the case manager (CM), facility administrator (FA), and daughter (Janice). CM: Ms. FA, I would like to help Mr. Foggy receive the rehab care and asso-
TABLE 1. MR. FOGGY’S CASE MANAGEMENT PLAN Barrier
Negotiation Strategy
Group speech therapy proposed for severe speech, language, and cognitive deficits likely ineffective
Negotiate appropriate individual speech/ cognitive therapy in the rehab plan
Costs exceed competition for comparable level of care
Negotiate competitive rate for rehab plan 5 days/week
Rehab needs to be provided on weekends to get most benefits
Negotiate for family to be taught community activities that complement rehab plan on weekend days; negotiate a competitive room/board rate for weekends so this could be accomplished
ciated funding he needs. I have reviewed his status, your proposed rehab plan, and the family’s perspective. I spoke with your admissions coordinator, and an appropriate and acceptable rehab plan has been identified for Mr. Foggy. He can be admitted when a bed is available. As you may know, your facility isn’t covered by his primary insurance. My concern is that his secondary policy covers this level of care at a “reasonable and customary (R&C)” rate. Your weekday rates exceed this rate by 25%, and your weekend rates, when he would receive only room and board, by 75%. If you can adjust your rates accordingly, we can work together to facilitate his admission as soon as possible. FA: I’m sorry, but the lowest rate I can offer is a 15% discount. CM: Sometimes the plan will expedite reimbursement. If they can reimburse you with a 15-day turnaround, would you be able to meet the R&C rate? If not, I will speak to the daughter to see if the family can afford the difference. FA: I will speak with our CEO to see if this is possible and get back to you soon. CM: Janice, I spoke to the admissions nurse about our concerns for group therapy, and she agreed that individual sessions for speech and cognitive therapy would enhance the plan and will be incorporated into the rehab plan daily Monday through Friday. This is good news, and a bed is available right
now. The only potential stumbling block at this point is funding for the plan. Your father ’s policy with Train Wreck, Inc., has a benefit for rehab, but it is based on reimbursement at what is called R&C rates in the insurance industry. We Care is significantly higher that what comparable facilities charge, which is what they base this on. I have tried to help with this by speaking with the administrator; she did agree to lower their rates to some degree, although not to the R&C level, and there still could be a balance. I don’t know if this is affordable for your father, but I have requested another adjustment. If this eventually results in incomplete coverage, I recommend that you speak with the administrator yourself to see if she might work with you to fund the care your father needs. What Skills Are Needed for Effective Negotiation? CMSA’s literature reports the following skills are needed by case managers for negotiating care and cost. They certainly would be useful for Mr. Foggy’s case negotiations. • Knowledge of issues (clinical, funding, service levels/models) • Interpersonal skills • Risk tolerance • Flexibility • Individualization • Reliability/follow through • Persuasion • Clear, concise, effective communication • Facilitation/problem-solving skills • Conflict management skills • Affirmation strategies January/February 2004
TCM 71
PREPARING TO NEGOTIATE: QUESTIONS TO ASK What is the opposing agenda? • We Care—opportunity to treat and help Mr. Foggy, funding for services • Client/family—optimal recovery, independence, funding for services Who has the power to negotiate? • We Care—the facility administrator • Client/family—Janice, the daughter What will be the consequences if agreement is not reached? • Possible inadequate care and compromised outcome • Lack of funding for care needed • Unnecessary and costly medical complications
Principles for Successful Negotiations Case managers who are frequently effective in negotiating have described guiding principles to live by. With these in mind, they gain the essential confidence for successful negotiations. Some of these tenets are described below with Mr. Foggy’s case as an example. Adopt the belief that conflict is natural in human interactions and predictable in situations involving families, clients, payers, and providers. The staff at the current skilled facility expressed anger and frustration with the complaints of Mr. Foggy’s family. Yet the case manager needed to negotiate with the staff to facilitate information and a smooth transfer to what they perceived as a competitor. Respect the people; attack the problem. Rather than accusing We Care of trying to exploit the system with their high charges, the case manager focused on the need to assist Mr. Foggy with funding and benefits. Focus on establishing trust and cooperation. The Foggy family initially did not trust the “insurance” case manager. Only when they could see that she was trying to help their loved one was this obstacle overcome. Be aware of your own interests and biases (beliefs, values, and attitudes). The fact that Mr. Foggy had a history of TCM 72
January/February 2004
alcohol abuse was something the Mormon case manager needed to recognize as potentially influential on her case management of him. Know/express what you want to achieve and confirm that all parties have the same goal (wellness/function, autonomy, resource value). Discussing the mutual goals of recovery and the funding to meet them allows everyone to focus on the goals and ways to accomplish them. Clarify or identify the perceived barriers and ensure everyone agrees on what the problem is. If the family does not see balance billing as a financial problem, why focus on it? Explore the various options and engage the client/family and provider to identify possible options (even if they do not seem viable). See if the administrator has any other ideas to help Mr. Foggy receive the care and funding he needs. Explore the consequences of the options and express any related concerns. In response to the administrator’s suggestion for their day program instead of an inpatient option, the case manager says it could present further concerns in that this model may not be as effective as a group model and also would be a greater financial burden on Mr. Foggy because he does not have any benefits to cover the cost. Ensure confidentiality. The case manager made certain that she had a medical release to discuss Mr. Foggy’s confidential information with others. Use third person language rather than first person. As a client advocate and outcome facilitator, it is important that the case manager refer to the client and family as the decision makers and owners of the benefits. Consistently referring to Mr. Foggy’s care needs and his plan and benefits rather than “our (health) plan” or saying “I don’t think that is necessary” is more appropriate for the advocate/facilitator role and does not give the impression that this negotiation is personal. Follow up. Allowing the negotiation process to lose momentum will be
unproductive. Promoting a “breather” period may be useful, but follow up is still important. Be flexible. Perhaps the family or administrator has a better idea! Maybe the family wants to and is able to take Mr. Foggy home for the weekend. Advocacy is not a matter of winning at all costs. Summarize the agreement in writing. To avoid any misunderstanding, a simple written statement of your understanding of the outcome of the negotiation, with copies to any stakeholder, is often important. Mr. Foggy’s family should receive a copy of any agreement that reflects his benefits and care plan. Negotiation is not for the faint of heart—but neither is true case management. ❑ References 1. Case Management Society of America. Standards of practice for case management. Little Rock (AR): The Society; 2002. 2. Davidhizar R, Shearer R. Persuading others to hear your ideas. J Care Management 1999;5:12-5. 3. Keffer MJ. Nurse advocate: advocate for whom? MedSurg Nur 1996;5:125-6. 4. Marino T, Yelland R, Kahnoski B. Communication action for case managers: techniques to manage conflict. Nursing Case Management 1998;3:36-45.
Sandra Lowrey, RN, CRRN, CCM, is president of CCMI Associates in Francestown, N.H. This article first appeared in the Second Quarter 2003 issue (Volume 12, Number 2) of ING Re ROSE Resource and was adapted for The Case Manager with permission from ING Re Group Life, Accident, and Health Reinsurance. doi:10.1016/j.casemgr.2003.10.012
Sandra Lowrey, RN, CRRN, CCM
C
ase managers are charged with the important role of trying to effect change to promote best outcomes.
Negotiating for care and cost-effectiveness is a frequent strategy with providers, payers, and clients. The Case Management Society of America’s (CMSA) national standards for case management practice indicate the case manager’s role in negotiating should include the following. TCM 70
January/February 2004
• Advocate and strive to achieve consensus among all parties to promote positive client health and wellness outcomes. When consensus cannot be achieved, the case manager should advocate and facilitate consensus through a review of viable alternatives, while encouraging the health care team to respect client/family choices. • Represent the client’s interests by advocating necessary funding, appropriate treatment, and treatment alternatives and by timely coordinating health services. • Educate and assist in facilitating client/family access to necessary and appropriate health care services. Case managers often find themselves having to “sell” their perspective. Whether negotiating with physicians, other providers, clients, family members, or other payers, we constantly try to
achieve better clinical and financial outcomes through negotiation. It always takes two parties to negotiate, so acquiring skillful negotiating techniques, while understanding where the other party is coming from, is critically important for successful case management. Consider the following case example in which the need for negotiating both care and cost is indicated. The names of both the client and company have been changed. Case Scenario Mr. Foggy, a 72-year-old single man, sustained an embolic stroke 2 months ago and received rehabilitation in a skilled rehab facility. His family was dissatisfied with his care and referred him to a specialized skilled brain injury facility, We Care, for rehab. The medical records and current treatment team describe severe aphasia and cognitive deficits, mild to moderate motor/sensory deficits, and moderate difficulty with balance. We Care is not a Medicare-contracted provider. Mr. Foggy’s secondary health insurer requested an independent case management assessment and recommendations. After reviewing the proposed treatment plan, which included “1 month of physical therapy, occupational therapy, and cognitive therapy 5 times a week supervised by a physiatrist,” the case manager contacted the family, who confirmed the facility’s assessment and explained that their dissatisfaction with the previous facility was based on a decubitus ulcer and inexperienced staff. They reviewed We Care’s proposed plan when they toured the facility and strongly wanted Mr. Foggy there because of the specialized and experienced staff and recommendations from other family members they had met in a support group. We Care was supportive and realistic in terms of outcome and long-term care needs. The case management plan shown in Table 1 includes the recommendations that require negotiation. In Mr. Foggy’s case, the negotiating might go something like this among the case manager (CM), facility administrator (FA), and daughter (Janice). CM: Ms. FA, I would like to help Mr. Foggy receive the rehab care and asso-
TABLE 1. MR. FOGGY’S CASE MANAGEMENT PLAN Barrier
Negotiation Strategy
Group speech therapy proposed for severe speech, language, and cognitive deficits likely ineffective
Negotiate appropriate individual speech/ cognitive therapy in the rehab plan
Costs exceed competition for comparable level of care
Negotiate competitive rate for rehab plan 5 days/week
Rehab needs to be provided on weekends to get most benefits
Negotiate for family to be taught community activities that complement rehab plan on weekend days; negotiate a competitive room/board rate for weekends so this could be accomplished
ciated funding he needs. I have reviewed his status, your proposed rehab plan, and the family’s perspective. I spoke with your admissions coordinator, and an appropriate and acceptable rehab plan has been identified for Mr. Foggy. He can be admitted when a bed is available. As you may know, your facility isn’t covered by his primary insurance. My concern is that his secondary policy covers this level of care at a “reasonable and customary (R&C)” rate. Your weekday rates exceed this rate by 25%, and your weekend rates, when he would receive only room and board, by 75%. If you can adjust your rates accordingly, we can work together to facilitate his admission as soon as possible. FA: I’m sorry, but the lowest rate I can offer is a 15% discount. CM: Sometimes the plan will expedite reimbursement. If they can reimburse you with a 15-day turnaround, would you be able to meet the R&C rate? If not, I will speak to the daughter to see if the family can afford the difference. FA: I will speak with our CEO to see if this is possible and get back to you soon. CM: Janice, I spoke to the admissions nurse about our concerns for group therapy, and she agreed that individual sessions for speech and cognitive therapy would enhance the plan and will be incorporated into the rehab plan daily Monday through Friday. This is good news, and a bed is available right
now. The only potential stumbling block at this point is funding for the plan. Your father ’s policy with Train Wreck, Inc., has a benefit for rehab, but it is based on reimbursement at what is called R&C rates in the insurance industry. We Care is significantly higher that what comparable facilities charge, which is what they base this on. I have tried to help with this by speaking with the administrator; she did agree to lower their rates to some degree, although not to the R&C level, and there still could be a balance. I don’t know if this is affordable for your father, but I have requested another adjustment. If this eventually results in incomplete coverage, I recommend that you speak with the administrator yourself to see if she might work with you to fund the care your father needs. What Skills Are Needed for Effective Negotiation? CMSA’s literature reports the following skills are needed by case managers for negotiating care and cost. They certainly would be useful for Mr. Foggy’s case negotiations. • Knowledge of issues (clinical, funding, service levels/models) • Interpersonal skills • Risk tolerance • Flexibility • Individualization • Reliability/follow through • Persuasion • Clear, concise, effective communication • Facilitation/problem-solving skills • Conflict management skills • Affirmation strategies January/February 2004
TCM 71
PREPARING TO NEGOTIATE: QUESTIONS TO ASK What is the opposing agenda? • We Care—opportunity to treat and help Mr. Foggy, funding for services • Client/family—optimal recovery, independence, funding for services Who has the power to negotiate? • We Care—the facility administrator • Client/family—Janice, the daughter What will be the consequences if agreement is not reached? • Possible inadequate care and compromised outcome • Lack of funding for care needed • Unnecessary and costly medical complications
Principles for Successful Negotiations Case managers who are frequently effective in negotiating have described guiding principles to live by. With these in mind, they gain the essential confidence for successful negotiations. Some of these tenets are described below with Mr. Foggy’s case as an example. Adopt the belief that conflict is natural in human interactions and predictable in situations involving families, clients, payers, and providers. The staff at the current skilled facility expressed anger and frustration with the complaints of Mr. Foggy’s family. Yet the case manager needed to negotiate with the staff to facilitate information and a smooth transfer to what they perceived as a competitor. Respect the people; attack the problem. Rather than accusing We Care of trying to exploit the system with their high charges, the case manager focused on the need to assist Mr. Foggy with funding and benefits. Focus on establishing trust and cooperation. The Foggy family initially did not trust the “insurance” case manager. Only when they could see that she was trying to help their loved one was this obstacle overcome. Be aware of your own interests and biases (beliefs, values, and attitudes). The fact that Mr. Foggy had a history of TCM 72
January/February 2004
alcohol abuse was something the Mormon case manager needed to recognize as potentially influential on her case management of him. Know/express what you want to achieve and confirm that all parties have the same goal (wellness/function, autonomy, resource value). Discussing the mutual goals of recovery and the funding to meet them allows everyone to focus on the goals and ways to accomplish them. Clarify or identify the perceived barriers and ensure everyone agrees on what the problem is. If the family does not see balance billing as a financial problem, why focus on it? Explore the various options and engage the client/family and provider to identify possible options (even if they do not seem viable). See if the administrator has any other ideas to help Mr. Foggy receive the care and funding he needs. Explore the consequences of the options and express any related concerns. In response to the administrator’s suggestion for their day program instead of an inpatient option, the case manager says it could present further concerns in that this model may not be as effective as a group model and also would be a greater financial burden on Mr. Foggy because he does not have any benefits to cover the cost. Ensure confidentiality. The case manager made certain that she had a medical release to discuss Mr. Foggy’s confidential information with others. Use third person language rather than first person. As a client advocate and outcome facilitator, it is important that the case manager refer to the client and family as the decision makers and owners of the benefits. Consistently referring to Mr. Foggy’s care needs and his plan and benefits rather than “our (health) plan” or saying “I don’t think that is necessary” is more appropriate for the advocate/facilitator role and does not give the impression that this negotiation is personal. Follow up. Allowing the negotiation process to lose momentum will be
unproductive. Promoting a “breather” period may be useful, but follow up is still important. Be flexible. Perhaps the family or administrator has a better idea! Maybe the family wants to and is able to take Mr. Foggy home for the weekend. Advocacy is not a matter of winning at all costs. Summarize the agreement in writing. To avoid any misunderstanding, a simple written statement of your understanding of the outcome of the negotiation, with copies to any stakeholder, is often important. Mr. Foggy’s family should receive a copy of any agreement that reflects his benefits and care plan. Negotiation is not for the faint of heart—but neither is true case management. ❑ References 1. Case Management Society of America. Standards of practice for case management. Little Rock (AR): The Society; 2002. 2. Davidhizar R, Shearer R. Persuading others to hear your ideas. J Care Management 1999;5:12-5. 3. Keffer MJ. Nurse advocate: advocate for whom? MedSurg Nur 1996;5:125-6. 4. Marino T, Yelland R, Kahnoski B. Communication action for case managers: techniques to manage conflict. Nursing Case Management 1998;3:36-45.
Sandra Lowrey, RN, CRRN, CCM, is president of CCMI Associates in Francestown, N.H. This article first appeared in the Second Quarter 2003 issue (Volume 12, Number 2) of ING Re ROSE Resource and was adapted for The Case Manager with permission from ING Re Group Life, Accident, and Health Reinsurance. doi:10.1016/j.casemgr.2003.10.012