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.