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There are many ways you can help children and their families get the care they need.
Patients receive health care in a number of different settings in today's managed care environment. This typically is based on what they need and what their insurance will cover. Insurers have different criteria for determining the setting or "level of care" that is required. The criteria most often are centered around the patient's condition, severity of illness, and intensity of care that is needed. At Boston Children's Hospital, the utilization management case managers play a key role in getting services approved at the appropriate level of care as defined by individual insurance policies. They provide information from the medical record and from communications with the multidisciplinary team to justify the medical necessity of patient care to insurers.
Please note: Coverage for health care services varies widely based on the type of insurer and coverage/conditions of individual policies. Patients and their families should familiarize themselves with the specifics of their insurance coverage to be sure they understand the rules they must follow and what their financial obligations for care may be.
The discharge planning case managers play a key role in ensuring that patients are moved safely and appropriately from one level of care to another. For example, they are responsible for helping to identify appropriate post-hospital care facilities, facilitate transfer arrangements and insurance approvals, and to complete referrals for home care services. They also work closely with patients and their families to evaluate needs and expectations and to make necessary arrangements for transition from one level of care to another.
The following are the main settings/levels of care that patients of Children's Hospital may need.
Utilization management broadly refers to services designed to evaluate the necessity, appropriateness, and efficiency of the use of medical services. It also includes advocacy and facilitating access to care. These services are provided in many settings, including insurance companies, hospitals, and managed care organizations. Goals include optimizing effective use of payer funds for services, maximizing timely reimbursement to health care providers, and evaluating variations in service delivery that impact the costs of care.
At Boston Children's Hospital, the utilization management case managers perform many functions. They assist with preadmission approvals for services that will be provided at our hospital. They review medical record reviews for our hospitalized patients in order to ensure continued approval for inpatient services. Likewise, they perform retrospective reviews and appeals of insurance denials for services that have already been provided by Children's Hospital clinicians.
In the sections that follow, we have included information regarding utization management in today's health care delivery system.
Center for Families
Patient Financial Services
Other helpful resources
Project School Care / MASSTART
Department of Public Health
Department of Intellectual Disability
Federation for Children with Special Health Care Needs
Massachusetts Commission for the Blind
Discharge planning is a process that evaluates a patient's needs after hospitalization. Care and services may be arranged to:
At Boston Children's Hospital, the Clinical Case Managers work with the multidisciplinary team to evaluate potential discharge planning needs from the start of a patient's admission. In some cases, they assist with proactive planning prior to a patient's elective admission to ensure assessment of and advanced preparations for post-hospital care needs. Likewise, they are available to assist with immediate post-discharge issues with care continuity and funding for medically necessary and appropriate care and services.
Activities performed by the Clinical Case Managers include the following:
Advocacy is a key component of case management practice. The primary goal of advocacy is to foster patient and family independence in managing their health care issues. Ensuring that patients and their families have knowledge and access to available services and resources is an integral part of a case managers role.
Examples of advocacy by case managers at Boston Children's Hospital include:
We are grateful to have been ranked #1 on U.S. News & World Report's list of the best children's hospitals in the nation for the third year in a row, an honor we could not have achieved without the patients and families who inspire us to do our very best for them. Thanks to you, Boston Children's is a place where we can write the greatest children's stories ever told.”