This episode is co-presented by the Association of PhysicianLeadership in Care Management and the American Case Management Association.

In this episode, returning experts Dr. Rebecca Severe andDr. Sweta Singh are joined by special guest Dr. Ariana Peters of Mayo Clinic to discuss two real-world cases that illustrate the complexities of determining medical necessity throughout a patient's hospital stay.

The first case explores a patient who remained hospitalizedafter becoming medically stable because she wished to complete additional diagnostic testing before discharge. The panel examines the ethical and operational challenges of balancing patient preferences with appropriateresource utilization, highlighting when inpatient care is no longer medically necessary and how multidisciplinary teams can navigate these difficult conversations.

The second case follows a patient who required ongoinghospitalization despite limited treatment options, prompting discussion around discharge planning, patient appeals, and the physician advisor's role in supporting frontline clinicians. Throughout both cases, the panel emphasizes the importance of clear communication, thorough documentation, interdisciplinary collaboration, and maintaining a patient-centered approachwhile ensuring hospital resources are used appropriately.

The Association of Physician Leadership in Care Management (APLCM) was created to provide support andeducation 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 ⁠[email protected]⁠ with questions, topic requests, or feedback.

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 [email protected]with questions, topic requests, or feedback.

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, along with guest Jason Lindsey, who is Director of Case Management at his organization.The conversation explores two complex case studies highlighting the intersection of medical necessity, ethical decision-making, and system-level barriers in patient care.The first case follows a critically ill, unidentified patient who presented with sepsis and required intensive, multidisciplinary care. With no identification, no confirmed family, and no decision-maker, the care team navigated significant challenges, including court-appointed guardianship, progression to gangrene requiring amputation, and long-term hospitalization due to the inability to secure post-acute placement. Over more than six years, the case evolved beyond clinical management into a complex discharge planning issue, requiring coordination across ethics committees, social work, legal systems, and external agencies.The second case examines a medically complex patient presenting with chest pain, heart failure, and subsequent complications, including pericarditis and acute kidney injury. Despite clear clinical indicators supporting inpatient level of care, the case was denied by the payer following a short length of stay due to the patient leaving against medical advice. The discussion highlights strategies for supporting inpatient status in the setting of evolving clinical conditions, the importance of thorough documentation of ongoing symptoms and medical decision-making, and key considerations when appealing payer denials—particularly when length of stay is impacted by patient-driven discharge.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 [email protected] with questions, topic requests, or feedback.

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.

In this episode, the conversation tackles two complex,real-world cases that highlight the gray areas of utilization management, patient status determination, and navigating payer expectations, especially when clinical trials and post-operative recovery blur the lines between observation and inpatient care. First, they unpack a challenging scenarioinvolving an elderly Medicare patient enrolled in a blinded clinical trial for a transcatheter mitral valve repair. With uncertainty around whether an inpatient-only procedure was actually performed, the discussion explores how to apply Medicare rules, protect patient benefits, and ensure compliance when documentation is intentionally limited.

Next, they dive into a surgical case involving a largethigh mass removal, where high drain output, IV antibiotics, and functional decline raise important questions about when it’s appropriate to convert from outpatient/observation to inpatient status,  and how to build a strong case during peer-to-peer reviews and appeals. Packed with practical insights, this conversation offers valuable strategies for physician advisors, casemanagers, and utilization review professionals navigating complex admissions, clinical trials, and post-operative care decisions.The Association of Physician Leadership in Care Management, or 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 the partnership and collaborative model of 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. Membership in APLCM also gives you access to all ACMA resources and benefits. Whether you're new to case management or have years of experience, APLCM membership is valuable. Gain access to professional networking opportunities and resources. Visit www.aplcm.org to learn more. Please visit www.acmaweb.org/podcast for more information about the podcast, or contact us directly at [email protected] with questions, topic requests, or other feedback.

In this episode, Dr, Sweta Singh and Jon Shreve explore how artificial intelligence is reshaping case management workflows while keeping human judgment firmly at the center of care decisions. Through real-world perspectives, the discussion examines how AI can reduce administrative burden, synthesize complex clinical information, and support more timely, informed decision-making—without replacing the expertise of case management professionals.

The conversation also dives into the evolving relationship between providers and payers, highlighting how clearer clinical summaries, improved documentation, and standardized data exchange can streamline authorizations and peer-to-peer reviews. From change management and team adoption to transparency, trust, and patient experience, this episode unpacks what it truly takes to integrate AI responsibly and effectively into healthcare operations.

This episode was sponsored by MCG Health: At MCG Health, we believe every patient deserves the right care at the right time. As part of the Hearst Health network, MCG delivers evidence-based clinical guidelines and AI-powered technology that guide case management professionals toward better outcomes for their patients. Over 3,000 hospitals, a majority of health plans, and many state and federal government agencies rely on MCG’s trusted, unbiased clinical guidance and AI to support accurate, efficient, and compassionate care decisions. With rigorous scientific processes at our core and innovation in our DNA, we help caremanagement organizations improve the patient journey while reducing unnecessary administrative burdens. MCG Health — the source of truth for clinical decisions. Learn more at mcg.com.

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, along with Kimberly Browne and Dr. John Eanes to share their insights on pediatric cases.

The conversation explores three complex pediatric cases that highlight the challenges of managing high-risk children with medical and behavioral complexities. The first case involves a four-year-old child with sickle cell disease and multiple comorbidities admitted with fever and respiratory symptoms, raising questions about inpatient versus observation status. The second case is a 16-year-old with a chronic liver condition who overdosed on Tylenol and faced extended hospitalization while awaiting inpatient psychiatric placement. The third case discusses systemic and logistical hurdles in coordinating care for medically fragile children across state lines, including insurance limitations, care transitions, and Medicaid complexities. The panelists reflect on the unpredictability of pediatric recovery, payer negotiations, and the importance of proactive communication with insurers.

The Association of Physician Leadership in Care Management, or 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 the partnership and collaborative model of 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. Membership in APLCM also gives you access to all ACMA resources and benefits. Whether you're new to case management or have years of experience, APLCM membership is valuable. Gain access to professional networking opportunities and resources. Visit www.aplcm.org to learn more.

Please visit www.acmaweb.org/podcast for more information about the podcast, or contact us directly at [email protected] with questions, topic requests, or other feedback.

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, along with Jennifer Dominow and Marla Kolovitz from Loyola Medicine to share their insights on navigating complex patient transitions.

This episode dives into three complex patient cases that reveal the real-world challenges of case management and utilization review—from surgical complications and readmission dilemmas to high-risk discharges and insurance barriers. The panel explores how legal coordination, interdisciplinary teamwork, and persistent advocacy can make all the difference.

The Association of Physician Leadership in Care Management, or 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 the partnership and collaborative model of 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. Membership in APLCM also gives you access to all ACMA resources and benefits. Whether you're new to case management or have years of experience, APLCM membership is valuable. Gain access to professional networking opportunities and resources. Visit www.aplcm.org to learn more.

Please visit www.acmaweb.org/podcast for more information about the podcast, or contact us directly at [email protected] with questions, topic requests, or other feedback.

Recorded live at the ACMA 2025 National Conference, Learning Link Live: Answers to Current Case Management Issues captures an interactive session where healthcare professionals across diverse roles came together to explore real-world challenges in case management. This unique experience, driven by live and remote audience participation, features expert panelists addressing key questions on Care Coordination, Transitions of Care, Utilization Management, Regulatory Models, and Outcomes.

This special session highlights the important role of physician leadership in care management through the Association of Physician Leadership in Care Management (APLCM). APLCM was created to provide education, resources, and support for physicians in care management and is uniquely connected to the American Case Management Association (ACMA), reflecting the collaborative model among nurse case managers, social workers, and physicians. APLCM is inclusive of all practice settings, offering valuable membership benefits whether you are new to case management or a seasoned professional. APLCM membership includes access to all ACMA resources and professional networking opportunities.

To learn more about APLCM, visit www.aplcm.org. For more information about this podcast and other sessions, visit www.acmaweb.org/podcast or reach out to us directly at [email protected] with any questions, topic requests, or feedback.

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, along with ACMA President Patti Velky who joins us for Season 4, Episode 1 to share her insights on navigating complex patient transitions.

The conversation revolves around three case studies highlighting the complexities of patient care transitions, medical necessity decisions, and systemic barriers in healthcare. The first case examines an elderly dementia patient experiencing frequent hospitalizations, emphasizing the challenges of coordinating care and determining the most appropriate long-term setting. The second case features a 30-year-old patient with severe neurological impairments and bowel obstruction, focusing on inpatient versus outpatient treatment decisions and the role of caregivers in medical management. The third case explores a medically complex patient facing insurance denials for a necessary procedure, underscoring the impact of documentation, coding issues, and advocacy in securing appropriate care. The discussion highlights the critical role of interdisciplinary collaboration, proactive care planning, and system navigation in optimizing patient outcomes.

The Association of Physician Leadership in Care Management, or 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 the partnership and collaborative model of 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. Membership in APLCM also gives you access to all ACMA resources and benefits. Whether you're new to case management or have years of experience, APLCM membership is valuable. Gain access to professional networking opportunities and resources. Visit www.aplcm.org to learn more.

Please visit www.acmaweb.org/podcast for more information about the podcast, or contact us directly at [email protected] with questions, topic requests, or other feedback.

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 three physicians, Dr. Rebecca Severe, a Hospital Medicine-certified physician serving as Medical Director of Care Management for Advocate Aurora Health, Dr. Sweta Singh, Medical Director of Care Management at the University of Michigan Medical School, and Dr. Teresa Jacobs, Clinical Professor of Neurology at the University of Michigan Medical School.

In this episode, the conversation revolves around two case studies focusing on the complexities of patient care transitions, particularly in cases of urinary tract infections (UTIs) in patients. The first case discusses a 45-year-old female with a complicated medical history who required inpatient care due to severe symptoms and treatment complications. The second case involves an 80-year-old female with vague symptoms and a history of UTIs, raising questions about the necessity of inpatient care versus observation. The discussion highlights the challenges of medical necessity determinations, peer-to-peer reviews, and the importance of follow-up care in managing patients with UTIs.

The Association of Physician Leadership in Care Management, or 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 the partnership and collaborative model of 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. Membership in APLCM also gives you access to all ACMA resources and benefits. Whether you're new to case management or have years of experience, APLCM membership is valuable. Gain access to professional networking opportunities and resources. Visit www.aplcm.org to learn more.

Please visit www.acmaweb.org/podcast for more information about the podcast, or contact us directly at [email protected] with questions, topic requests, or other feedback.