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As the pressure increases for case managers to help ensure that hospitals comply with payer requirements and get paid appropriately, physician advisors can be a valuable ally.
As financial stakes rise for hospitals and pressure increases on case managers, your new best friend may be your physician advisor.
With new initiatives and audits from the Centers for Medicare & Medicaid Services (CMS) and commercial payers following suit, case management has evolved into being a key role in the hospital, says Elizabeth Lamkin, MHA, chief executive officer and partner in PACE Healthcare Consulting, LLC, based in Beaufort County, SC.
“The case management role is one that bridges the clinical and the financial side of healthcare, and the physician advisor is a vital link between the C-suite, case management, and the medical staff,” she says.
“There are so many changes coming forward from the government and private payers that it is critical for hospitals to have a physician advisor whose duties go far beyond the traditional role of reviewing for patient status,” says Donna Hopkins, MS, RN, CMAC, vice president at Novia Strategies, a national healthcare consulting firm.
Physician advisors can provide valuable expertise for case managers, whether they are discharge planners, responsible for utilization management, or coordinating care, says Cheryl Warren, MS, RN, CMAC, chief clinical integration officer for Hallmark Healthcare, a network of community hospitals and health centers in the Boston area.
“Physician advisors have expertise in the clinical part and they have credibility with the medical staff. Many case managers do have great relationships with the medical staff but they aren’t physicians, and for that reason they often find it difficult to challenge a physician. The physician advisor can review the chart, then mediate with the treating physician,” she says.
Physicians are more likely to change patient status, add to the documentation, or move a patient to the next level of care if the suggestion comes from another physician, says George W. Nunn, MD, a retired general surgeon and lead physician advisor at DCH Health System, a three-hospital system with headquarters in Tuscaloosa, AL.
“Some physicians have a hard time accepting it when anybody tells them what to do about their patients, but when they hear it from a physician who has been in practice they can accept it better,” Nunn says.
When physicians don’t follow payer requirements, it’s often because of a lack of education, adds Yvonne Focke, RN, BSN, MBA, a Cincinnati-based independent case management consultant.
“Most physicians haven’t been immersed into the regulatory world. They are concerned with caring for their patients and don’t understand the importance of documentation, appropriate patient status, and getting the right language on the order,” Focke says.
Physician advisors can be the solution because they understand both sides, Lamkin says. “Physician advisors live in two worlds. They are trained on how the hospital works and know how to interpret regulations for the medical staff. They also bring management input from the medical staff,” Lamkin says.
When physician advisors and case managers combine their knowledge, they can become experts on what is needed for the hospital to comply with regulations and get paid appropriately, Lamkin says.
Physician advisors know the medical staff, have expert knowledge of the disease process, and gain expertise from the case managers who understand throughput and utilization, she adds.
There are several different models for physician advisor arrangements, Focke says. Some hospitals have one full-time physician advisor; others may have multiple physicians, often hospitalists, who rotate in the role. “These physicians are still practicing. They are credible and respected and can help with the decision and educate physicians on the spot,” she says.
Some hospitals outsource physician advisor duties to large organizations, Hopkins adds “It really works better if you have physician advisors who are on staff or retired from the hospital because they know other physicians,” Hopkins says.
“In order to be most effective, the physician advisor should know the other physicians in the hospital. It doesn’t work as well to have outsiders or someone calling from a different state in the role,” Nunn says.
Warren’s hospital has a physician advisor for case management who is physically on hand to assist case managers with issues such as moving patients to the next level of care and who chairs the utilization management committee. The hospital contracts with an external company for utilization, payer billing, level of care, and insurance issues.
“Whether it’s part time or full time, hospitals need to have a physician advisor as a resource to help get everything right on the front end and avoid denials,” Lamkin says.
In the past, hospitals didn’t have to deal with so much regulation that directly affects reimbursement, Lamkin points out. “But in today’s world, we have to rethink how to manage the system,” she adds.
Hospitals can no longer wait 24 hours or longer to get patient status right. It has to be right on the front end, Lamkin says. And with a wide range of auditors scrutinizing patient records, the documentation has to clearly reflect the condition of the patient and the services provided in order for the hospital to get paid appropriately and in a timely manner, she adds.
The appeals process is a lengthy and resource intensive process, especially if it goes to the administrative law judge level, Focke points out. Even if the hospital wins the appeal of a denial, the payment will be delayed by at least 90 to 120 days and the cost of the appeals may exceed the amount recouped, she adds.
“Even when hospitals win, they still lose. Getting everything right up front brings value when the hospital gets paid but beyond the actual dollars, hospitals avoid the time and cost involved in writing the appeal,” she says.
Despite attempts by CMS to provide clarity, the Two-Midnight Rule hasn’t made patient status any clearer for many practitioners, Focke says. “A physician advisor can help the case manager review an observation case before the second midnight to determine if it is appropriate to convert it to inpatient. Even if the case is converted only 10% of the time, it can add significant dollars to the bottom line,” Focke says.
In another scenario, the physician advisor can step in when the case manager isn’t able to convince the admitting physician that a patient who is expected to stay only overnight doesn’t meet the criteria for an inpatient admission and should receive observation services as an outpatient, Lamkin says.
Physician advisors often can help case managers ensure that patients get the right care in the right place, and at the right time, Warren says.
They can be called on to mediate when the attending physician and the case manager disagree on whether the patient is ready for the next level of care, Warren says.
For instance, the case manager may feel that a patient has met clinical goals and asks the treating physician to collaborate on a post-acute destination. But the physician feels the patient should stay longer, although the case manager points out that the patient no longer meets medical necessity.
“Many times, a physician advisor can persuade the treating physician to move the patient along,” Warren says. For instance, the physician advisor can suggest discharging the patient with home health services or outpatient therapy.
“Physician advisors are effective in getting patients moving along the continuum and making sure the documentation supports the care that is rendered so the hospital can be properly reimbursed,” Warren says.
They can help eliminate testing and procedures that could be done on an outpatient basis, Focke says. For instance, an elderly patient who is hospitalized for pneumonia may need other tests, such as a colonoscopy, that are unrelated to the reason for the admission.
“When a patient is dependent on their family for transportation, getting them back and forth for tests isn’t easy for the patient and family, and physicians may order tests in the hospital for their convenience. But this isn’t using resources wisely and Medicare will not reimburse for care that can be provided on an outpatient basis,” Focke says.
Physician advisors must have a visible presence in order to be effective, Nunn advises.
“Physician advisor is not a desk job,” Lamkin adds. “The physician advisor should be out making rounds, leading the interdisciplinary team in rounds and reviewing patient status when referred by the case managers. If they’re not making rounds, they’re not forming relationships,” she says.
Nunn recommends assigning case managers and physician advisors to the same unit or service line. “This makes the structure flow more smoothly and helps them develop good working relationships,” he says.
He suggests that case managers also have a visible presence so everyone on the unit knows who they are. “They can’t just sit in an office and work on the computer or talk to the nursing staff. Case managers have to be on the floor, working with physician advisors and the physicians on the unit,” he says.
Financial Disclosure: Managing Editor Jill Drachenberg, Associate Managing Editor Dana Spector, and Editor Mary Booth Thomas, report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study. Nurse Planner Toni Cesta, PhD, RN, FAAN, Consulting Editor of Hospital Case Management, is a consultant with Case Management Concepts LLC.