1. Ongoing review of cases by clinical professionals to ensure the necessity of the clinical services given and most appropriate use of services to a patient. Typically, case managers are nurses or social workers. They may operate privately or may be employed by social service agencies or public programs. 2. Process that integrates and coordinates patient care in complex and high-cost cases. Sometimes a patient is referred to as case managed. 3. Process of developing a defined health care plan for a patient for better communication and to improve quality of care and reduce costs. Case management is sometimes a “carve out.” See carve out. 4. In the Medicare program, an arrangement of services needed to give proper health care to a beneficiary; tracking of beneficiary’s use of facilities and resources. Also known as catastrophic case management, catastrophic claim management, large claim management, or medical case management.
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Case management is used to manage healthcare costs in workers compensation. The case manager works with the insured, the physician, and the employer to design the most cost-efficient treatment plan. Case managers also monitor the injured worker’s progress and keep the employer and insurance company informed about the worker’s ability to return to work.

1. Clinical professional (nurse or social worker) who works with the patient and all those involved with the patient in coordinating a plan of medical necessity and appropriateness of health care. He or she reviews cases after a predetermined amount of time and certifies ongoing care. 2. Registered or licensed vocational nurse assigned to a workers’ compensation case to supervise the administration of medical or ancillary services provided to the patient.

Distribution of patients into categories reflecting differences in severity of illness or resource consumption. These categories include age, medical diagnosis, severity of illness, or length of stay. A nursing home or hospital’s actual case mix influences cost and scope of the services provided by the facility to the patient, and case mix reimbursement systems adjust payment rates accordingly.

1. Average relative weight of all cases treated at a facility or by a certain physician that reveals the clinical severity of a defined group in relation to other groups in the classification system. Formula: Divide the sum of the weights of diagnosis-related groups (DRGs) for patient discharged during a specified period by the total number of patients discharged. A low CMI may indicate DRG assignments that do not adequately reflect the resources used to treat Medicare patients. 2. In prospective payment systems, this is the comparison of a hospital’s cost for its case mix to the national or regional average hospital cost for a similar case mix.

Mathematical method used to determine the case mix index by taking the sum of all diagnosis-related groups’ (DRGs’) relative weights and dividing it by the number of Medicare cases.

1. Numeric assigned by the insurance carrier (payer) to an insurance claim. When appealing a denied or rejected claim, it must appear on each page of the document that is submitted to the payer. 2. See group number.