Medical Case Management Explained

Leave a Comment
May 17th, 2012

What is Medical Case Management?

medical case managementThe 2009 CMSA approved definition of Case Management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality cost-effective outcomes.

The basic concept of medical case management involves the timely coordination of quality services to address a client’s specific needs in a cost-effective manner in order to promote positive outcomes.

Who is involved with Medical Case Management?

The parties that are generally included in case management are as follows, but this is however not an exhaustive list: Payers, Providers, Patients, Family Members, and the Case Manager. Case Managers are medically trained individuals (doctors, nurses, social workers, etc.) that are also experienced in dealing with administrative and financial best practices. They ensure that the right amount of intensity and urgency are given to each medical case.

Why is Medical Case Management important?

“Payers continue to seek methods for reducing costs while advancing quality and transparency. Providers explore methods to define and report quality while maximizing reimbursement.” – CMSA Standards of Practice for Case Management.

Case Managers use financial, ethical and legal standards to act as a liaison between the patient and the provider. Case Managers should include the following in their service to their client:

  • Advocacy & Education: ensuring the patient has an advocate for needed services and any needed education. The case manager should increase involvement of the individual and caregiver in decisions.
  • Clinical Care Coordination/Facilitation: Coordinating multiple aspects of care to ensure the patient progresses.
  • Continuity/Transition Management: Managing resource utilization and reimbursement for services. Minimizing fragmentation of care and focusing on transitions of care in an effective, safe, timely and a complete manner are high priorities.
  • Performance & Outcomes Management: Monitoring, and if needed, intervening to achieve desired goals and outcomes for both the patient and the hospital.
  • Psychosocial Management: Assessing and addressing psychosocial needs including individual, familial, environmental, etc.
  • Research & Practice Development: Identifying practice improvements and using evidence-based data to influence needed practice changes.


At PayerFusion, we feel that case management services are key to facilitating the speedy and complete recovery of patients. By offering case management services, we take a proactive approach to cost containment. As a case is actively followed, we can monitor progress, foresee a range of billing situations and plan to handle them promptly so all parties receive timely service. This ensures quality service to the patient, a clean case by reducing billing errors for payers and prompt payment to the provider. Case management not only informs and monitors the patient but also fuses the gap between payers and providers to ensure a hassle-free reimbursement process. For more information on what PayerFusion can provide, please visit our services and for more detailed information on our  medical case management services.

One Comment

  • This is a very interesting position and I hope the Cross Border Healthcare industry takes notice of the level of professionalism that exists in the USA for patients, payers and providers.

    The "Medical Tourism" industry as a whole has been misguided with the concept of price being the driver and people flocking in droves for low cost treatment.

    Certainly, cost is a factor and perhaps for self pay individuals its important but for commercial payers cost containment and services of making the process run smoothly go hand in hand.

    Overall, the medical tourism industry has a great deal to learn from Cost Containment companies that have been working this model in the USA for years and the U.S. is by by far - the largest market for inbound treatments and has been for years.

    Well done in explaining what Case Management involves and for raising the bar on what a "Medical Facilitator" should be capable of handling!