Care Transitions Today Podcast

Case by Case: Status Determination When the Path Isn't Clear

This episode is co-presented by the Association of Physician Leadership in Care Management and the American Case Management Association. In this episode, we are joined by returning experts Dr. Rebecca Severe and Dr. Sweta Singh.

In this episode, the conversation tackles two complex, real-world cases that highlight the gray areas of utilization management, patient status determination, and navigating payer expectations, especially when clinical trials and post-operative recovery blur the lines between observation and inpatient care. First, they unpack a challenging scenario involving an elderly Medicare patient enrolled in a blinded clinical trial for a transcatheter mitral valve repair. With uncertainty around whether an inpatient-only procedure was actually performed, the discussion explores how to apply Medicare rules, protect patient benefits, and ensure compliance when documentation is intentionally limited.

Next, they dive into a surgical case involving a large thigh mass removal, where high drain output, IV antibiotics, and functional decline raise important questions about when it’s appropriate to convert from outpatient/observation to inpatient status, and how to build a strong case during peer-to-peer reviews and appeals. Packed with practical insights, this conversation offers valuable strategies for physician advisors, case managers, and utilization review professionals navigating complex admissions, clinical trials, and post-operative care decisions.

The Association of Physician Leadership in Care Management, or APLCM, was created to provide support and education for physicians in this field. APLCM is unique because of its connection to the American Case Management Association, focusing on the partnership and collaborative model of nurse case managers, social workers, and physicians in care management. ACMA has a rich, 25-year history of supporting the case management field. APLCM is inclusive of all practice settings. Membership in APLCM also gives you access to all ACMA resources and benefits. Whether you're new to case management or have years of experience, APLCM membership is valuable. Gain access to professional networking opportunities and resources. Visit www.aplcm.org to learn more. Please visit www.acmaweb.org/podcast for more information about the podcast, or contact us directly at podcast@acmaweb.org with questions, topic requests, or other feedback.