The Necessity of Your Hospital Stay

Case Management

The case management department is staffed by licensed professional nurses and physician advisors who are responsible for the ongoing assessment and evaluation of each patient’s level of care in order to deliver quality, cost-effective healthcare and the efficient use of hospital resources. Case managers are responsible for monitoring the care of patients throughout their entire hospitalization. They assess and identify patients who may require care post-discharge and initiate appropriate referrals to social work. They work closely with the patient, family, physician, social worker, nursing staff, other members of the health care team and the patient’s insurance company to determine the appropriate level of care for each patient. The case managers support the physician by providing information, suggestions, test results, payer concerns, etc. and help to establish an individual plan to meet each patient’s specific needs.

Federal law requires that hospitals maintain a utilization management program to determine whether a patient’s hospital admission and continued stay are medically necessary. The case managers are responsible for monitoring the care of patients throughout their entire hospitalization and for communicating information about each patient’s medical condition to their insurance company when requested.

Medicare, Medicaid, and other insurance companies utilize specific criteria to determine a patient’s need for admission and continued care in a hospital. Changes in the healthcare delivery system have resulted in shorter hospital stays and many procedures previously requiring hospitalization are now performed in outpatient settings, skilled nursing facilities or in the patient’s home. If it is determined that you no longer require inpatient hospital care you will be notified that your insurance company will no longer cover your stay. This does not mean that you no longer require care. It means that your care could be provided elsewhere, such as in a physician’s office, outpatient setting, skilled nursing facility, or in your home. Should you choose to remain in the hospital you may be responsible for all costs incurred after the date your insurance company determined that your stay was no longer necessary.

If you do not agree with either the hospital’s or your insurance company’s determination about your hospital stay, the case management staff will explain the appeal process and assist you in appealing the decision. Also, there may be times when we as a hospital, as well as your physician, may disagree with your insurance company’s determination about your hospital stay. In these situations the case management department will assist in appealing this decision with your insurance company on your behalf.

For more information you may contact the case management department.

Perth Amboy Location
8:30 a.m. to 5:00 p.m.
Monday through Friday
732.324.5043

Old Bridge Location
8:30am – 5:00pm
Monday through Friday
732.360.4264