The Impact on the Care Coordination Team

While every hospital strives to provide the best possible patient care, each hospital must also ensure that it maintains the fiscal discipline necessary to ensure its long-term viability.

As the cost of healthcare continues to rise, many payers have shifted toward value-based purchasing methodologies and have become more proactive in reviewing the appropriateness of payment claims both concurrently and retrospectively. For example, the federal government, in its efforts to reduce Medicare and Medicaid waste and fraud, has identified billions of dollars improperly paid throughout the past few years.

One area of focus for governmental and commercial payers is the medical necessity of care provided and the setting in which such care is delivered. With this increased scrutiny of medical necessity, today’s hospitals must implement robust utilization review (UR) processes to ensure the delivery of appropriate care. The hospital’s UR plan is the standard by which the hospital will be judged to be in (or out of) compliance with Medicare’s Conditions of Participation.

The concept of the physician advisor has evolved to assist the hospital with ensuring compliance with the Medicare Conditions of Participation and the delivery of appropriate care. Ten years ago, the role of the physician advisor, as we currently know it, did not exist. There was no operational role for a physician in the hospital, other than that of delivering clinical care.

Today’s physician advisor functions as a liaison between treating physicians, case/utilization management and hospital administration. In the past, this role was filled by a part-time clinician who voluntarily undertook such duties or had taken an interest in UR. But this is no longer the case. With frequently changing rules, regulations and policies, physician advisors require a specific expertise and command of complex knowledge within their subject matter. With patient care being delivered 24 hours a day, the role of the physician advisor has quickly transformed from a part-time, to five days per week full-time, to seven days per week position.

The following are a few of the key job functions of a physician advisor:

• Serving as an expert advisor to the hospital’s UR Committee.
• Conducting second-level medical necessity reviews for all patient cases that do not meet first-level screening criteria for an inpatient admission. All factors mandated by CMS must be considered during this review, including:
  • The patient’s medical history and current medical needs.
  • Facilities available to meet these needs (inpatient and outpatient).
  • The severity of the signs and symptoms exhibited by the patient.
  • The medical predictability of something adverse happening to the patient.
  • The hospital’s by-laws and admissions policies; and the relative appropriateness of treatment in each setting.
  • Findings of evidence-based diagnostic studies that could assist in decision making.
• Coordinating the process and documentation of proper Medicare Condition Code 44 use, when appropriate.
• Assisting with effective management of lengths of stay.
• Investigating the most suitable post-short-term acute care setting options.
• Educating treating physicians on rules, regulations and strong physician documentation practices.
• Facilitating communication between managed care organizations and the hospital regarding benefit coverage issues, utilization review and quality assurance processes.
• Conducting verbal and written reviews and appeals of denials or downgraded coverage determination made by managed care organizations.
• Managing governmental appeals process for inappropriate denials on behalf of the hospital, including representing the hospital during Administrative Law Judge hearings.
• Remaining up-to-date on ongoing regulatory guidance changes, managed care/hospital contract updates, and the latest evidence-based care guidelines and outcomes.
• Tracking and analyzing ongoing payer trends across the facility.

It is clear that employing strong physician advisors, whether in-house or outsourced, is a necessity for today’s hospitals. As the healthcare industry continues to evolve, so too will the role of the physician advisor.

 

Dr. Michael Taylor is the Vice President of Clinical Operations for Executive Health Resources. Dr. Taylor is an expert in the fields of medical necessity utilization review and compliance and has vast experience in assisting hospitals throughout all levels of the Medicare appeals process, including the Administrative Law Judge level of appeal. Contact: mtaylor@ehrdocs.com