Does Your Facility Need a Physician Adviser?
By Beth Walsh
Few would doubt that a physician dedicated to helping a hospital’s medical staff improve documentation and compliance can help improve the facility’s billing efficiency and its resulting bottom line. This recognition, in addition to the need for hospitals to be compliant with Medicare’s and Medicaid’s Conditions of Participation has resulted in the growth of the role of physician adviser from a position that could once be filled by a semi-retired physician for a few hours a week to a necessary important operational medical necessity compliance and revenue integrity overseer available 7 days a week, according to Joseph Zebrowitz, MD, executive vice president at Executive Health Resources (EHR) in Newtown Square, PA.
Zebrowitz said that the physician adviser is “an incredibly difficult role to develop internally. The physician adviser role has evolved to encompass many different skill sets.” Today, a physician adviser must be an expert in medicine as well as Medicare regulations.
Growing Interest and Need
EHR provides outsourced physician adviser services to more than 300 hospitals and health care systems in the United States, ranging from 50 beds to more than 1,200 beds. Zebrowitz says that the company has seen significant national growth over the past 18 to 24 months and doesn’t expect that to slow down any time soon.
All hospitals can benefit from physician adviser services, he said. Smaller hospitals have the challenge of finding and training the right personnel, while larger hospitals, especially academic medical centers, are often so layered and complex that it’s difficult for them to coordinate a legally compliant and accountable internal physician adviser program.
A physician adviser process offers “the opportunity to unify departments that haven’t always worked together,” Zebrowitz noted. Those departments include finance, nursing, medical staff, case management, compliance and more. Oftentimes, when he runs an initial meeting at a client facility, the attendees realize they’ve never all met together before. “It’s time for these silos to get together because they each have a stake in regulatory compliance.”
From medical necessity investigations by the Office of Inspector General (OIG) to upcoming compliance challenges, such as present on admission and MS-DRGs, overseeing and tracking medical necessity compliance is “a job for more than one person,” Zebrowitz said. The many operational and knowledge base components of a good medical necessity compliance program make outsourcing an attractive option, he explained. A basic operational best practice is the need to run the program 7 days a week. “Medicare doesn’t care if a questionable case is discharged on a Tuesday or a Saturday,” he said. “Compliance is a 7-day-a-week requirement.”
Training is another challenge for one internal physician adviser. Introducing new employees to policies and procedures and ensuring the hospital’s processes are up-to-date legally is a big responsibility. Meanwhile, “the reimbursement rules and regulations are so complex and constantly changing that any program must be able to efficiently and validly manage such changes to avoid compliance risk and exposure,” Zebrowitz said.
Establishing an in-house physician adviser role is another option. To do so, “work with the hospital or corporate administrative leadership, medical staff leadership and quality councils to perform cost/benefit justification to assess how the role of a physician adviser could integrate within your organizational structure,” said Carol Spencer, RHIA, manager, professional practice resources for the American Health Information Management Association.
“It is a key hospital leadership role and interacts, influences and represents the hospital in making improvements in documentation that support patient care, quality measures, reimbursement, compliance and hospital report cards.”
Spencer advises that having “extended arms for this role is critical to success. For example, concurrent clinical documentation improvement programs with clinical or coding staff on the nursing units is a viable solution. Having a position such as a physician adviser to assist the clinical documentation improvement team is invaluable to moving ahead in making documentation improvement efforts stick.
Decreasing Denials and Risk
A high rate of claims denials usually are the result of “processes that just don’t work,” said Zebrowitz. A good concurrent process is important, he noted. Retrospective reviews are too late and force facilities to write off reimbursement they are due. Reviewing and correctly certifying claims “as close to the time of submission as possible is the first step in appropriately managing the revenue cycle.”
Spencer recommends moving the process to pre-admission. “Having the hospital work with the physician office staff and insurance company before admission or outpatient test is critical to reducing denials,” she said. Having a physician write an appeal letter often helps overturn appeals, she added.
However you choose to improve your compliance, Zebrowitz said that now is the ideal time to do it. The establishment of recovery audit contractors, which focus on medical necessity, is forcing facilities to take a closer look. Last year’s OIG Work Plan was amended to preclude recovery audit contractors (RACs) from investigating facility claims prior to Oct. 1, 2007. However, RACs are creating a database that can be accessed by the OIG and the OIG can look much further back than Oct. 1, 2007, when investigating fraud and abuse claims.
“There’s a unique opportunity right now for hospitals to protect themselves going forward by creating compliant processes to eliminate auditor red flags,” he said. “It’s double jeopardy-you can either solve your problems now or open yourself up to scrutiny from the past and into the future. There’s no middle ground.”