The Case Management Society of America, CMSA, defines medical case management as the coordination of appropriate health and social services so that an individual can reach the highest possible level of physical and mental functioning after an injury or illness. It is a collaborative process of assessment, planning, facilitation, and advocacy for services to provide clear direction in the pursuit of medical care, thus helping an individual reach his or her rehabilitation goals.
The essential purpose of case management is to optimize the quality of life for an injured individual and for his or her family. The ultimate aim of case management services from SCM Associates, Inc. is to maximize the well-being of an individual whose life has been disrupted and sometimes permanently altered by an accident, injury, or chronic health problem.
The underlying principle of case management is to achieve the optimum level of wellness and functional capability for the patient, thereby enabling everyone to benefit: the individuals being served, their support systems, the health care providers, and the various sources of reimbursement.
Case management serves as a means for achieving client wellness and autonomy through advocacy, communication, education, identification of service resources, and service facilitation. The case manager helps identify appropriate providers and facilities throughout the continuum of services, while ensuring that available resources are being used in a timely and cost-effective manner. Case management services are best offered in a climate that allows direct communication among the case manager, the client, and appropriate service personnel, in order to improve the outcome for all concerned.
Common Barriers to the Healing Process
- Lack of understanding of medical terminology by the patient
- Failure of the patient to follow medical or rehabilitation recommendations
- Lack of pertinent information being made available to the medical provider in a timely manner
- Difficulty making contact with medical or rehabilitation providers outside of treatment sessions
- Lack of coordinated care among medical or rehabilitation providers
- Differences of opinion between the patient and the medical or rehabilitation provider
- Feelings of frustration in the patient
- Lack of care coordination between stages of care
SCM provides case management services to payors of healthcare, as well as to trust funds, individuals, employers, and other case management organizations. We strongly believe that improved patient care will reduce the costs to all parties involved. A coordinated healthcare plan helps to alleviate wasted time and resources, as well as establishing an effective plan of action.
Health Insurance Providers
The rising costs of healthcare have triggered a more in-depth analysis of how claims are processed and the cost allowed for services to members. This is especially true for the costs associated with catastrophic cases that disproportionately consume funds. One way healthcare companies have tried to find a balance to these rising costs is the utilization of case managers as intermediaries who can coordinate multiple service providers and ensure that the patient is getting the care they need to reach their optimal level of recovery in a timely manner.
Examples of common cases where healthcare companies would require case management assistance are catastrophic or large claim management programs, maternity case management programs, and transitional care management programs. By identifying patients with potentially catastrophic illnesses, contacting them and actively coordinating their care, plans can reduce expenses and improve the medical care their participants receive.
Private Companies and Employers
Employers face multiple problems associated with employee absenteeism and managing the effects of lost productivity. Proactive intervention is sometimes needed to facilitate an employee’s recovery and timely return to work. Many employers are beginning to engage the services provided by nurse case managers in their Return-to-Work programs, aimed at accomplishing these goals in order to achieve more positive medical outcomes, minimize litigation, and increase, or at the very least leverage, productivity concerns.
By providing health education, following up on work absences due to poor health or chronic illness, and verifying reasons for employee absenteeism employers hope to reduce the costs incurred from employees missing work, and they are better able to plan for those who need to take extended leaves of absence.
Workers’ Compensation Carriers
In instances that involve worker’s compensation carriers, case managers coordinate the physical rehabilitation of a worker injured on the job. Using case management services can help to effectively facilitate medically necessary services and to promote optimal patient outcomes. This approach can reduce the period of disability, and assure a high quality of care at an appropriate cost.
The shortage of government- and community-funded programs has increased the need for case managers to establish client linkages to reimbursement programs and to increase access to medical, social, or vocational agencies in order to resolve issues of medical care, housing and employment. Case managers in these programs are usually particularly skilled at meeting the social needs of patients, providing transportation, and assuring that clients keep their appointments at the various agencies are important components of their activities. This type of case management is probably the most established of all, and it has provided the foundation for other care providers to adopt its techniques.
We follow the standards of practice for Case Management as produced by the Case Management Society of America, CMSA. http://www.cmsa.org/SOP
Certification determines that the case manager possesses the education, skills, and experience required to render appropriate services based on sound principles of practice.
The Commission for Case Management Certification, CCMC, developed a scope of practice for Case Managers as a representation of professional opinions regarding what constitutes appropriate delivery of effective case management services. It is considered unethical for case managers to operate outside of their individual scope of practice limits.
The experience SCM has gained from being in the case management industry for more than 20 years affords us the expertise needed to attain the outcomes our clients and patients want and need. We attribute this success to:
- The quality and professionalism of our staff
- Our staff’s high level of experience
- Flexibility of our services
- Our focus on quality of care
- Commitment to quality of care
Credentialing is a process used to assess the qualifications and practice history of healthcare professionals. Most health care organizations are required to credential their providers to ensure proper education standards and work history have been met.
Major accrediting organizations include the National Committee for Quality Assurance (NCQA) and The Joint Commission. These independent, nonprofit organizations set quality standards for health care companies, credentialing organizations and hospitals. The process includes a review of a doctor’s or other health care professional’s completed education, training, and licenses. It also includes any certifications in the provider’s area of specialty.
Due to the changing dynamics of the health care industry this process can be time consuming and costly, which is where SCM can step in to help complete the process in a timely, cost effective manner.
SCM contracts with many different health care organizations around the country, including hospitals, surgery centers, independent practices, health care plans, and private facilities.
Our specialty, knowledge, and experience enable us to provide services nationwide to both large and small organizations. No matter your verification needs, SCM’s staff is here to help you through the process.
Many facilities have their own bylaws and guidelines that they must follow, which means that flexibility and knowledge are essential in providing credentialing services. SCM stays up to date on the various credentialing standards, continually developing our knowledge base to meet the needs of every organization. Our credentialing process conforms to the specifications of the various accrediting organizations such as NCQA, The Joint Commission (formerly known as JCAHO), AAAHC, and URAC.
SCM Associates has a strong commitment to quality service that results in cost reduction. We tailor our services to meet your organization’s needs, whether that means full-service credentialing and monitoring or just a single verification. SCM will work to make the credentialing process easier for you.
We have over 15 years of experience and expertise in the credentialing industry, and we assist new medical facilities to establish credentialing guidelines as well as to educate professionals who are new to the process. Our service and commitment to excellence are what help SCM in creating winning working relationships.
SCM strives to stay abreast of technological advances in the industry, and we use an up-to-date program with web connectivity. Through a secure login portal from our website clients can download applications, gain access to their applicant data, follow the verification process, and submit missing information. We have stringent security controls in place to protect your information, maintain confidentiality, and provide HIPAA compliance. Allowing real-time access to records enables our clients to get the documentation they need and speeds the process along from start to finish.
The credentialing process does take time to complete due to the significant amount of paperwork involved, but SCM guarantees a specified turnaround time on complete applications or your services are discounted. Due to the type and nature of primary source verification much of the process relies on the response time of others. To minimize these delays SCM follows ups multiple times by email, fax, and phone to obtain responses as quickly as possible.
The answer is yes. One of SCM’s core philosophies is its excellence in personalized service to all our clients. When a client sets up an account with SCM we assign a customer service representative to your account and that person becomes your primary point of contact to handle all aspects of your credentialing needs.
To obtain your NPDB number you can go online to their website at http://npdb-hipdb.hrsa.gov/ and print out the application form. Fill this out and mail it in, keeping a copy for your records. They will mail you your NPDB number once they have approved your application. At that time, you can authorize SCM as your agent, and contact us for our NPDB number, at which time we can advise you on the process.
This information is set up as soon as you arrange for services with SCM. Your customer service representative will send you all the information to log in and view your records. If you have misplaced this information, please contact your customer service representative and they will send you the instructions.