Legal Issues Related to Case Management

  • Autor de la entrada:
  • Categoría de la entrada:Sin categoría

«The case manager should represent the client`s interests by advocating for necessary funding, appropriate treatment and alternatives, timely coordination of health services, and frequent reassessment of progress and goals. Recognizing that client advocacy may conflict with the need to balance cost constraints with limited health care resources, the case manager must continually self-assess his or her decisions to maintain client advocacy. «These questions contribute to ethical dilemmas and sometimes frustration. You shouldn`t be defensive if customers/support systems tend to focus their business activities on reducing costs or limiting their offering. The mere fact that case management is a tool for reducing health care costs is, on its face, ethically commendable. Anything that can be done ethically to reduce health care spending is indeed a good thing. The Case Management Society of America (CMSA) published the «Standards of Practice for Case Management» in 1995. These standards contain numerous references to the ethical obligations of a case manager to the patient, regardless of who hired them. For example, page 9 of the CMSA standards states: With respect to ethical issues, the CMSA standards on page 19 read: Given that the majority of case managers are trained in nursing, social work or vocational rehabilitation, They should be aware of the need to only proceed with case management plans for their clients that have already been approved by the client`s surrogate or legitimately designated agent. According to Hogue, the best protection case managers have from liability is to know and understand the national standards of care published by the Case Management Society of America, based in Little Rock, AR. The «Scope of Practice» section of the Code states that case management is guided by five ethical principles (2015, p. 3).

These are fundamental and deserve your utmost attention. Case managers who keep abreast of developments in case management will fare much better than those who don`t, she says. Even the most responsible case manager is likely to receive a complaint at some point, Lambert warns. Here are some steps case managers can take to protect themselves and their hospitals: According to Hogue, another contentious issue is liability for unfavourable payment decisions. «It`s still a very open topic,» she says. Case managers sometimes claim they have no responsibility because doctors make treatment decisions, she adds. «I think they`re really burying their heads in the sand when they say that,» she warns. «I don`t think it works from a legal standpoint.» According to Lambert, legal problems can arise for case managers in a variety of ways. Patients can file complaints with hospitals or payers about the treatment they have received.

These complaints can be directed to quality assurance or patient representatives, or to risk management if the incident occurs. Reports may also be submitted to state councils, medical examination boards, nursing boards or pharmacy committees. In addition, complaints may be registered with Medicare. In these situations, if the case manager adequately meets his or her ethical obligations under the CMSA standards and other applicable ethical principles, he or she should inform the patient, as the patient`s advocate, of the need to protect his or her legal rights. Often, this is exactly what case managers do. In other cases, unfortunately, this is not the case. A review of the relevant literature shows that increasing attention is being paid to ethical issues in case management. The literature acknowledges that case managers hired by insurance companies have significant obligations to patients that should go beyond loyalty to the insurance company that hired the case manager.

According to Lambert, case managers should also understand the alternatives that can be offered and ensure patients are aware of these alternatives as well as the appeal process. She says case managers should learn how to present patients` options without letting the conversation become personal. «Don`t try to make it a face-to-face exchange,» she says. Ethical restrictions on case managers include, but are not limited to, informing the client if they have reason to believe that the client`s rights have been violated, compromised or are about to be violated. A case manager cannot stand idly by and do nothing if they know that the insurance company has taken actions that are or may be inconsistent with the insurer`s legal obligations under the Michigan Non-Fault Act. This may mean that a case manager must recommend or approve a certain level of care and treatment that the insurance company does not consider necessary or necessary. A case manager who puts his or her own economic interest above that of the patient in this situation is not behaving in accordance with the ethical standards of the CMSA. According to Kathleen Lambert, JD, RN, a veteran nurse and practicing lawyer in Tucson, Arizona, the most common sources of litigation and legal issues for case managers come from discharge planning. Overall, the CMSA standards clearly show that the primary responsibility of the case manager and his or her loyalty to the patient is to be found. If the case manager has to choose between saving money on insurance or promoting and improving patient care, treatment and rehabilitation, the patient`s interests must be controlled.

Access to information is also becoming a very important legal issue. This is especially true for case managers who work in the employee comp space, as they often struggle to access the information they need, Hogue says. However, the requirements of the Health Insurance Portability and Accountability Act are likely to make this an issue that all case managers will face. Whether case managers realize this or not, they may be involved in disputes over their treatment decisions and recommendations. But in addition to this threat, several steps can be taken to mitigate their responsibility. Case management measures to comply with ethical standardsA case manager. Case Manager: 2. Act as an advocate for clients to ensure that information is provided to the client in order to make informed health decisions and encourage informed consent.

5. Use appropriate and reliable resources and advice to formulate ethical decisions. Veracity is the ethical principle that requires you to tell the truth to your clients/support systems, your professional colleagues, and any other person or entity you deal with in the course of providing case management services. Finding the truth adds value to both you as a case manager and your customer/support systems. Case management is guided by the principles of autonomy, charity, non-malevolence, justice and sincerity. Autonomy is defined as «a form of personal freedom of action when the individual sets his own path according to a plan of his choice.