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.

The conversation explores two case studies highlighting the complexity of medical necessity decisions and evolving payer policies in healthcare. The first case centers on a high-risk pregnancy involving a 35-year-old patient with a history of multiple pregnancies and a shortened cervix at 25 weeks. Despite a short hospital stay, the clinical team determined that inpatient care was necessary due to the severity of the risks to both mother and baby. Through peer-to-peer discussion with the payer, the team successfully demonstrated the medical necessity based on high-risk factors, fetal monitoring, and steroid treatment.

The second case examines the impact of a new payer “severity payment” policy affecting inpatient reimbursement. A patient undergoing an inpatient-only cardiac procedure initially received a reduced payment based on the payer’s severity classification despite appropriate inpatient admission. The discussion highlights strategies for navigating new reimbursement models, identifying payment downgrades that may not appear as traditional denials, and adapting hospital workflows to ensure appropriate reimbursement. Together, these cases illustrate the importance of clinical advocacy, collaboration with specialists, and proactive monitoring of evolving payer policies to ensure that patient care decisions and reimbursement accurately reflect the complexity of the cases being managed.

The Association of Physician Leadership in Care Management (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 a collaborative model that brings together 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, and membership provides access to ACMA resources and benefits. Whether you're new to case management or have years of experience, APLCM membership offers valuable professional networking opportunities and resources. Visit www.aplcm.org to learn more.

For more information about the podcast, please visit www.acmaweb.org/podcast or contact us directly at podcast@acmaweb.orgwith questions, topic requests, or feedback.

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, along with guest Jason Lindsey, who is Director of Case Management at his organization.The conversation explores two complex case studies highlighting the intersection of medical necessity, ethical decision-making, and system-level barriers in patient care.The first case follows a critically ill, unidentified patient who presented with sepsis and required intensive, multidisciplinary care. With no identification, no confirmed family, and no decision-maker, the care team navigated significant challenges, including court-appointed guardianship, progression to gangrene requiring amputation, and long-term hospitalization due to the inability to secure post-acute placement. Over more than six years, the case evolved beyond clinical management into a complex discharge planning issue, requiring coordination across ethics committees, social work, legal systems, and external agencies.The second case examines a medically complex patient presenting with chest pain, heart failure, and subsequent complications, including pericarditis and acute kidney injury. Despite clear clinical indicators supporting inpatient level of care, the case was denied by the payer following a short length of stay due to the patient leaving against medical advice. The discussion highlights strategies for supporting inpatient status in the setting of evolving clinical conditions, the importance of thorough documentation of ongoing symptoms and medical decision-making, and key considerations when appealing payer denials—particularly when length of stay is impacted by patient-driven discharge.The Association of Physician Leadership in Care Management (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 a collaborative model that brings together 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, and membership provides access to ACMA resources and benefits. Whether you're new to case management or have years of experience, APLCM membership offers valuable professional networking opportunities and resources. Visit www.aplcm.org to learn more.For more information about the podcast, please visit www.acmaweb.org/podcast or contact us directly at podcast@acmaweb.org with questions, topic requests, or feedback.

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 scenarioinvolving 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 largethigh 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, casemanagers, 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.