✅ Reviewed for accuracy and relevance by Deanna Cooper Gillingham, RN, CCM, FCM on July 24, 2025.
Case managers must adhere to all federal, state, and local laws and regulations governing their practice, including those related to client privacy, confidentiality, and professional licensure. According to CMSA’s Standards of Practice, case managers are responsible for ensuring compliance with legal and ethical obligations and must work within the scope of their professional license and discipline.
If an employer’s policies conflict with legal requirements, the law takes precedence. In such cases, case managers should seek guidance from legal counsel, compliance officers, or regulatory agencies to ensure they uphold professional and legal standards.
Mandatory reporting
Healthcare professionals are legally required to report certain incidents to protect vulnerable individuals from harm. These mandatory reporting laws vary by state but generally include:
- Child abuse and neglect
- Elder and dependent adult abuse
- Injuries from violence
- Sexual assault
- Public health threats
Mandatory reporters acting in good faith are protected from civil and criminal liability. Healthcare workers who fail to report suspected abuse or required incidents may face fines, license suspension, or criminal charges. Since laws vary by state, case managers should be familiar with reporting requirements for all the states in which their clients reside.
Interstate compact for nursing
Nurse case managers must generally be licensed in the state where the client is located. Telephonic case managers who manage cases across state lines are typically required to hold a nursing license in the client’s state unless an exemption applies. The Nurse Licensure Compact (NLC) allows nurses to practice in all compact member states with one multistate license. To qualify, the nurse must reside in an NLC member state and meet uniform licensure requirements. Nurses should always check state-specific regulations to ensure compliance.
Like nurses, social workers are generally required to be licensed in the client’s state. While a Social Work Licensure Compact is in development, it is not yet active in most states. Until it is fully implemented, social workers must obtain individual state licenses to practice across state lines.
Corporate compliance
Corporate compliance consists of policies, procedures, training, and enforcement mechanisms to prevent misconduct and ensure compliance. The U.S. Department of Health and Human Services Office of Inspector General provides guidelines for healthcare compliance programs. A compliance program should include the following elements:
Written policies and procedures – Organizations must establish clear policies and procedures that outline staff legal, ethical, and regulatory expectations.
Compliance oversight and leadership – Organizations should designate a Compliance Officer or create a Compliance Committee.
Training and education – Regular compliance training is required to keep healthcare staff informed.
Communication and reporting systems – A confidential reporting system should allow employees to report potential compliance violations without fear of retaliation.
Monitoring and auditing – Organizations must regularly perform audits to identify compliance risks.
Disciplinary actions and enforcement – A compliance program should include a clear disciplinary policy for handling violations. Consequences for non-compliance should be consistently enforced.
Corrective action and continuous improvement – If an issue is identified, the organization must take prompt corrective action to address the compliance violation and prevent recurrence through policy changes, training, or process adjustments.
Use of technology
The Health Information Technology for Economic and Clinical Health (HITECH) Act aimed to enhance healthcare quality, safety, and efficiency by promoting electronic health records (EHRs). The following technology objectives aim to improve care coordination and patient outcomes.
Electronic prescribing (eRx)
Objective: Generate and transmit permissible prescriptions electronically, enhancing prescription accuracy, reducing medication errors, and expediting patient access to necessary medications.
Electronic exchange of summary of care
Objective: When transitioning or referring patients, provide a comprehensive summary of care record to the next provider or care setting. This ensures continuity and coordination of care, reducing errors and promoting patient safety.
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