Care Delivery and Reimbursement Methods
Care settings and payment mechanics
Case managers must connect need → benefit → setting → authorization → documentation. Know the continuum: acute inpatient, observation, IRF, SNF, LTAC, home health, hospice, outpatient, and community-based care. Reimbursement models include fee-for-service, capitation, DRG/prospective payment, bundled payments, shared savings/value-based care, and managed care. Medicare Part A covers inpatient hospital, SNF with a qualifying stay, some home health, and hospice; Part B covers physician/outpatient/DME; Part D covers drugs. Medicaid is federal-state and varies. Workers' compensation and auto liability follow injury-related rules.
Traps
Questions often swap setting with payer or confuse eligibility with authorization. Observation is not inpatient and generally does not satisfy the SNF qualifying stay. Home health requires homebound status and intermittent skilled need-not custodial care. SNF requires daily skilled care; custodial care is not covered. Hospice emphasizes comfort and palliation, not curative treatment. “Medically necessary” and “authorized” are not synonyms.
Worked example
A patient needs IV antibiotics and daily wound checks but is otherwise stable. If homebound with an intermittent skilled need, home health may fit; if daily skilled nursing and a qualifying hospital stay are documented, SNF may fit. Rule of thumb: verify the benefit first, then the setting, then authorization and documentation.