By Angela Mounsey, BSN, RN, CCM, CPHQ
One of the most dreaded responsibilities of a case manager is having to issue a letter of non-coverage to a patient or their family. It’s the moment when the care team determines that the patient no longer meets medical necessity for acute care—or for continued stay—and the responsibility to explain that reality falls squarely on the case manager’s shoulders. I’ve encountered many of these situations over the years, but one particular case has stayed with me.
We had a long-stay patient who had reached a point where a discharge plan had been created: transfer to a nursing home under hospice care. The plan had been discussed and agreed upon with the patient and her family. Everything seemed in place—until the financial realities came to light.
The nursing home informed us that the patient had used all of her Medicare days. When we looked deeper, we discovered she had nearly exhausted her lifetime reserve days as well. She wasn’t enrolled in Medicaid. And when the topic came up, the family refused to consider it. They were adamant about not spending down assets or taking any financial steps that could impact what they felt should be protected. The patient’s family member, who also served as Power of Attorney (POA), told us repeatedly, “She has always paid her bills,” and felt strongly that asking for help from Medicaid would go against the patient’s values.
We tried to explain the reality of the situation. In the state of Indiana, Medicaid requires applicants to meet financial eligibility criteria, which include using assets to pay for care before qualifying for coverage. We explained that the patient’s assets needed to go toward her care, not toward preserving them for others. To offer additional support, we connected the family with an elder law attorney who could help them explore legal options to protect some of the assets while navigating the Medicaid application process. The attorney worked diligently with them, but even with expert guidance, the family still refused to move forward.
The discharge planner kept trying to coordinate a safe discharge, but without a viable payment source or agreement from the POA, we had no path forward. At this point, the patient no longer met medical necessity to stay in the hospital. We had to issue a Hospital-Issued Notice of Non-Coverage (HINN) for continued stay.
This was not a decision we took lightly. These conversations are hard. They’re emotional. But in the end, we must advocate not only for the patient’s care but also for responsible and appropriate use of healthcare resources.
Eventually, the situation escalated to involve the Quality Improvement Organization (QIO), which independently reviewed the case and confirmed that the patient no longer required acute care. That ruling meant the family would be responsible for the cost of the hospital stay beginning the day after the QIO’s determination.
Only after this did the family agree to move forward with the original discharge plan. The patient was successfully transferred to the nursing facility where she had always wanted to go, and the elder law attorney continued working with the family to preserve what assets they could, within the limits of the law.
This case reminded me that being a case manager is not only about coordinating services—it’s about navigating incredibly difficult situations with empathy, integrity, and persistence. Sometimes, we have to be the bearer of hard truths. And sometimes, we’re the bridge between families and the tough decisions they need to make.
It’s never easy to say “no,” but saying it with compassion—and backing it up with knowledge and resources—can help families move forward, even when the road is rocky.
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Bio: Angela Mounsey is the Manager of the Quality Improvement/Care Continuum Department at Marion General Hospital.