Concurrent Admission Reviews – Physician Advisors will review Medicare and Commercial cases in any instance where the patient’s clinicals fail to meet Utilization Management screening criteria (Milliman / Interqual) or when the payor disagrees with the physician’s patient status determination. They will apply medical necessity definitions and medical judgment (consistent with evidenced based standards of care) to cases in order to ensure that contractual compliance and federal compliance is achieved. Physicians will intervene in cases as per the following:
Issue a Stay Type determination to Utilization Management
Provide individualized case documentation supporting the decided upon level of care.
Work within the parameters of the Utilization Management Committee as defined by Medicare Conditions of Participation (42 CFR 482.30) when applicable to Medicare patients
Consult with the attending as needed for documentation of additional clinical information
Provide education to the attending physician when case documentation is lacking needed information supporting the inpatient stay.
Concurrent Admission Denials Reviews and Appeals – Concurrent reviews and appeal services are conducted when payor claim status for inpatient services has been downgraded or denied and the patient is an inpatient at the time or has been recently discharged from the facility (Usually granted a 0-14 day post discharge window of time to appeal). A denial or downgrade is considered anything less than 100% of what the reimbursement would have been had the entire inpatient stay been approved and paid. The physician advisor will perform a telephonic appeal (peer-to-peer) with the appropriate payor representative in order to overturn denial as needed. The physician advisor will support the attending physician by providing the clinical criteria met using Milliman. They will also coach the attending in preparation for their conversation with the payor.
Approach Team Health and Stat Care about their commitment to perform Peer-to-Peer on their own patients with the PA group to provide coverage when they are off service or transferring service (will have to verify that we can do that with Humana?) Pursue having NP performing the P2P.
Cover when attending refuses to perform.
Retrospective Compliance Denials Review and Appeal - Retrospective reviews and appeal services are conducted when payor claim status for inpatient services has been downgraded or denied after the facility has received an explanation of benefits (“EOB”) or has received a formal letter notifying the hospital that a claim has been denied. A denial is defined as payment received which is anything less than 100% of what the reimbursement would have been had the entire inpatient stay been approved and paid. Includes: commercial denials, federal payor denials, QIO denials, OIG denials, etc.
Representation at Corporate UM Committee and / or facility UM Committee
Continued Stay Reviews (Needs to be further defined with Case Management)
Case Management Resource – When a patient meets discharge screening criteria and the attending “refuses” to discharge, case will be referred to physician advisor for review and intervention. The physician advisor will discuss with the attending the case in an effort to get the patient discharged so as to avoid having to send to the QIO. When sent to QIO, the hospital is held financially liable for all charges while the case is reviewed and a determination is rendered. Having the physician advisor intervene will hopefully alleviate the financial burden to the hospital, decrease length of stay and improve O:E ratio.
Peer-to-Peer with Attending regarding discharge planning opportunities
Clinical Documentation Advisor
DRG validation, quality reviews prior to final coding—HAC’s, PSI’s, etc.
The physician advisor will work with the clinical documentation improvement staff to facilitate documentation necessary to support the principle diagnosis. As the industry changes, DRG assignment is becoming increasingly difficult to defend. For example: a diagnosis of Sepsis must be supported by the clinical indications for Sepsis. It is no longer accepted that documenting Sepsis in the discharge summary is sufficient. The physician advisors will assist in identifying which cases are sent for query when the documentation does not clearly support the diagnosis assigned by the attending / consulting physician.
Need to assist physicians in order to decrease the query burden which will be placed on them due to ICD-10 transition.
Medical Necessity Education
New physician hires - Off site review of charts for their first 30 with intervention as needed.
Continued Education for existing physicians on an as needed basis
Minimum Experience: Prior clinical experience. Knowledgeable in evidenced-based medicine and demonstrate strong clinical judgment.. Basic skill set and/or knowledge base in utilization management. Excellent interpersonal and communication skills. Strong collaboration skills with other physicians and utilization management staff. Commitment to life long learning with willingness to complete educational opportunities related to the position.
License Requirement: Current TN Physician license
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