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.

In this episode, Dr, Sweta Singh and Jon Shreve explore how artificial intelligence is reshaping case management workflows while keeping human judgment firmly at the center of care decisions. Through real-world perspectives, the discussion examines how AI can reduce administrative burden, synthesize complex clinical information, and support more timely, informed decision-making—without replacing the expertise of case management professionals.

The conversation also dives into the evolving relationship between providers and payers, highlighting how clearer clinical summaries, improved documentation, and standardized data exchange can streamline authorizations and peer-to-peer reviews. From change management and team adoption to transparency, trust, and patient experience, this episode unpacks what it truly takes to integrate AI responsibly and effectively into healthcare operations.

This episode was sponsored by MCG Health: At MCG Health, we believe every patient deserves the right care at the right time. As part of the Hearst Health network, MCG delivers evidence-based clinical guidelines and AI-powered technology that guide case management professionals toward better outcomes for their patients. Over 3,000 hospitals, a majority of health plans, and many state and federal government agencies rely on MCG’s trusted, unbiased clinical guidance and AI to support accurate, efficient, and compassionate care decisions. With rigorous scientific processes at our core and innovation in our DNA, we help caremanagement organizations improve the patient journey while reducing unnecessary administrative burdens. MCG Health — the source of truth for clinical decisions. Learn more at mcg.com.

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 Kimberly Browne and Dr. John Eanes to share their insights on pediatric cases.

The conversation explores three complex pediatric cases that highlight the challenges of managing high-risk children with medical and behavioral complexities. The first case involves a four-year-old child with sickle cell disease and multiple comorbidities admitted with fever and respiratory symptoms, raising questions about inpatient versus observation status. The second case is a 16-year-old with a chronic liver condition who overdosed on Tylenol and faced extended hospitalization while awaiting inpatient psychiatric placement. The third case discusses systemic and logistical hurdles in coordinating care for medically fragile children across state lines, including insurance limitations, care transitions, and Medicaid complexities. The panelists reflect on the unpredictability of pediatric recovery, payer negotiations, and the importance of proactive communication with insurers.

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.