Cost Projections...

Specialties Case Management


Now working as a feild based case manager for worker's comp and auto insurance companies. They always want a cost projection.

Does anyone else have to do this? I hate all things financial! I am a nurse not a freaking accountant!!

Anyway, being that I have to dela with it, I am finding it so difficult to obtain information from the hospitals. They say, why do you need this info, this bill was already paid? Or, they don't have all the charges and don't know what other billing co was used, ex anesthesia, surgeons fees (they are copperative at least!) and cost of orthopedic hardware, THAT one is so elusive, they won't give you even a range of prices when you call the companies that manufacture them.

DME equiptment, and home care, PT, all of that is cool, but the hospital's billing procedures is a true problem, and I don't know how to give an accurate cost projection at all.

Can you get copies of the paid itemized bills from the adjusters or the insur co's themselves. Seems a little stupid to ask for info from them, since they want you to give them projections. Right now, I have 3 surgical cases coming up, they want cost projections, and I have no idea how to figure it.

Any ideas? MY sup hasn't been too much help. I have lots of sample reports, all are done so differently, and a small idea of what anesthesia would charge $85/per 15 min unit, but how do I know how many units would be used? I never get this when I call.

I can't seem to find any web sites that list this kind of info. How do you get this info for your cost projections?

When you do cost projections say for a case that was opened to tele CM in Feb, and the person had MRI's, PT, esi's, etc, now will have surgery, do you go back to the former costs and include them, or just from the future on? It doesn't make sense to me to dig into the past fees as these are already known to the insurance company since they must have already paid them, so what do you do?



835 Posts

This is always a dilemma in case management. There are so many variables in cost analyzing - how much insurance covers, if there are discounted fees with the facility, if the procedure codes are "bundled", or the office charges are "global".

What I used to do when working with some facilities on a regular basis was try to establish a relationship with the billing person. Usually they can tell you what the customary fees are for certain procedures.

DME companies usually have a price list they can share - Medicare has specific rates for HCPC codes. For instance, an ACL brace (sometimes referred to as a "Don Joy" Brace) is usually $1,000.00. I had to rely a lot on Medicare rates to determine costs. Their rates might be available on their website.

Also, when dealing with different states, the rates are different. California is HIGH. Most CT scans here are under $300.

Figuring hospital costs are a bear. Here in Nevada we used the method of using a daily rate. If the person was in ICU, we figured the daily per diem rate in ICU was $1,200. Sometimes, if you just know what the per diem rates are, you can use that to estimate the cost.

I'm assuming the claims examiners are asking you cost projections in order to set their reserves..?

hoolahan, ASN, RN

1 Article; 1,721 Posts

Specializes in Home Health.

Thank you vegas!! I just labored two hours on this projection (OK, so it was b/c I was doing it during commercials of the BB3 show!)

Yes, it is so the examiners can set their reserves. Make friends with the billers? I did send one a thank you note just today! :) I know where my bread is buttered. Bottom line is, the adjusters usually have all the intila bills, I'd say over 50% of the time, so why they pay us to do this is beyond me! Why they can't send us this info is also beyond me. Our reports would be so much more accurate. I am infalting all the costs so be sure they will have a cushion, b/c I knwo I am missing some like some surgoens include the post-op visits in the surg fee, some don't. :rolleyes:

a CT scan for 300?? I am not sure about that one, but an MRI in jersey is 1800. daily hosp rate between 5000- 8000, ICU bed 5000-12000!!!

Currently, I have a man who has been in the ICU since august, and heard today that he will likely be a long-term vent dependent, IF he survives, but the nurses tell me they don't think he will. I met him, and I have been calling his wife regularly. This man was the kind who busted his hump at work, all his employees loved him, and his wife is just falling apart. All that, and I have to figure how much this will cost?? I feel like just saying "Astronomical!!"

Thanks for your input Vegas!! I see you are advising and educating about cm all over the forum today. We are lucky to have a resource as knowledgeable as you!!

PS Just found out I am eleigible to take the CCM exam in October. I have had NO time to study, but hopefully the OJT will help alot!


835 Posts

I'm glad you have interest in getting your certification!

I forget to come over here and read the posts, I'm trying to be more proactive in getting people interested in this field. I feel it is an area of nursing has a great deal of potential. There so many great nurses that no longer can do bedside nursing for whatever reason who can make a wonderful impact as case managers.

Specializes in Case Management, Life Care Planning.

Great advice on making friends with the adjusters and billing folks. Also, your state may issue a fee schedule. Check with the WC authority (here in Ohio it's the BWC). A lot of times, it will give you specific fees for individual CPT and HCPCS codes or will tell you the percentage of billed charges they will pay based on the procedure (ie, inpatient, outpatient, ACS). The more you do this, the better you'll get at it.

I really, really miss Case Management....

Vegas' idea is the way I used to go. I additionally used a program called "Flashcode"'. You enter in the ICD-9, CPT or HCPIC Code, it will give you usual costs for medicare and private treatments, procedures and surgeries...In your area. It will unbundle codes for you (Doctor visit codes tacked onto a procedure. It will advise you the appointment is included in the procedure code) and a slew of other things like relative values and LOS based on a code (Kinda like M&R or InterQual). I don't know if you'd find the other stuff useful, but you'd enjoy entering a definition and getting a list of applicable CPT codes and their usual cost.

Ok...After all that's said, there is a cost for the program. It ranges from $300.00 and up for the software. Its easy to install and really is worth it.

You can download a one month free trial at :

Hope this is helpful!

Originally posted by hoolahan

All that, and I have to figure how much this will cost?? I feel like just saying "Astronomical!!"

I'm not familiar with WC, but can I try to take a stab at an idea? :idea:

Is there a department that handles catastrophic cases? IPA I worked at they had a department we would forward our transplants and high-end LTC members to. If they exist at your job, they can dang near give you a pretty accurate figure off the top of their head!

hoolahan, ASN, RN

1 Article; 1,721 Posts

Specializes in Home Health.

Rebel, you are AWESOME!!! I will buy the program, and deduct from my income taxes, for sure!!!!

As far as suport from my employer...well, all I can say it everything is very fragmented. Billing is done at an office in another state, and I don't even know those people.

I have one very complicated case right now, the mother, who just quite simply does not understand my role, despite repeated explanations, has decided not to cooperate with me at all. She has contacted every provider, and also instructed them not to give any info to me (DUH, do you want to be paid??!!) So, I have absolutely no medicals, and they wanted a cost projection. Bottom line, I made it up 100%.

I am nagging the adjuster to share what she has with me, turns out there was a major fall thru the cracks on their end and this case basically sat on a shelf unattended for months, now it is rush rush to me....DUMP! And that is cool, it's my job, but geez help me out here!

Finally the adjuster send me a copy of a report from OUR billing dept which indicated they have receievd biilling for 28surgical codes and 24 CPT codes.....say what?? And this came from my company and was dated 6 weeks earlier!!! I was peeved to say the least. Talk about looking like an azz!

I called my sup and said look, I realize we put a disclaimer on the cost proj, but I like my work to reflect my conscientious work ethic, and making up numbers out of the thin air and begging for medicals puts me in a bad light, esp when I find out the info has made it to my own company, it looks like the right hand doesn't know what the left one is doing. I think we need to re-evaluate out processes here!!!!!

So, here I sit w my hands completely tied on this case. I wrote the mom a lovely letter, but I bet she won't reply to me. Frankly, I don't need her aggravation, she will learn soon enough she should have cooperated with me, and I am sure I will have to re-open the case.

So, that is my frustration...too much fragmentation. That and having my sup make me seperate skilled home nursing and PT between 2 network providers RIGHT after I closed a deal w the VNA. I protested strongly, and she kept saying "Just blame it on me..." I felt like saying, then YOU call them, b/c I completely disagree. The clmt will still get the care needed, but what a PIA after the fact.

Can you say micromanagement????????? THAT is why I want to get enough experience to go independent. I don;t want to be micromanaged any more!!!!!

PLEASE post how this one turns out! It's amazing that your client has gotten anything without any cooperation! Good luck on this one Hoolahan!


835 Posts

Unfortunately, this happens all too often when working with claims offices. They get new examiners who are poorly trained on setting reserves, and they rely on the nurse case manager to give them insight. It's not fair to the new case manager because if he/she hasn't been given some overall guidelines to work with and base cost projections on, that case manager feels like they are being thrown to the wolves.

The optimal case management company should have in it's orientation and/or reference materials cost projection worksheets and figures to use for cost analysis. If they don't provide this, they should have someone on staff who is available to assist with these projections so it doesn't tie up that case manager's time.

I agree Vegas...It really isn't the responsibility for the "nurse" case manager to figure out analysis, billing or provider services. However because I got tired of seeing billing let a lot of $$$ go down the drain, I used flashcode, MnR, and relative values to approve or deny a request for authorization. I then entered in my notes WHAT I approved.

I guess the way systems were set up at my old job, I could enter an authorization and approve it, but It really was no way to see what exactly I was approving. A CPT & ICD-9 code appeared, but no where to see modifier's or agreements set up between provider services and MD's for fee-for-service versus capitation. best, But I pride myself for saving my company moolah, as opposed to watching it go bankrupt and wondering why.

hoolahan, ASN, RN

1 Article; 1,721 Posts

Specializes in Home Health.

I bow to you oh wise sages of case management. I am so green with this kind of CM!

Well, I did get the darn 3 pages of medicals from our company on the unco-op case. Got the name of a trauma doc. Called their billing dept, they were so happy to know it wasn't a self-pay, as she was originally recorded as, multi-trauma, out of it upon arrival to the ER, etc... In exchange, I sent the biller a PIP/AUTH for an itemized bill!! I alreday did the projection, but this will be handy for other cases. I am stating a binder, and them I will make a web site for FREE for new CM's!!!! :D

Then I called the hospital, same deal, got the bills, not too far off, but I fiugured two CT scans, she had head, sinuses, abd, pelvis, and x-rays TNTC!! So now I have a good idea of how many x-rays and CT scans are done on a multi-trauma as r/o basis.

I composed a letter to the doc, so when the insur co gets their bill, the doc MUST send a written report or record.

Do you beleieve we have to pay for med rec's from a hospital?? How cheasy!! $10 to search, then $1 per page.

I decided to call the radiology dept, sent her the PIP auth to get the written x-ray and CT scan reports. She promised she would send them, but didn't. I'll nag her again on Monday, NO fee either!!! So, just by some detective work, I will finally get some notes.

I had a great last 2 days. I was lucky enough to see great pt's, super-duper docs, and was very busy, and very productive. Also found out my critical pulm man is off the vent. I am sure he may yo-yo as most pt's who have been on long-term vent support do, but it's a step in the right direction. I'm really glad for him. He has a tremendous team of docs and nurses on his case!!!

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