Frequently, physician advisors are asked what value we bring to our facility. Physician advisors don’t produce billed services – a benchmark typically used by hospital administrators to measure value. While adequate in the past, those days are long gone. Every payer demands accountability. While not directly producing billed services, physician advisors, a key part of utilization review (UR), provide essential accountability – and can function as force multipliers, if used correctly.
It remains frustrating to hear repeatedly “why are you so expensive? What are you doing? Can’t it be done cheaper?” One wonders who is beating this drum. Is it a hired consultant, promising enticing results? Anyone involved in UR recognizes the gaps in our processes and opportunities to improve. All these areas require more full-time equivalents (FTEs), and subsequently more money, not less, to cover needs appropriately.
Wouldn’t we all like to get better documentation (complete, and directed to diagnoses and treatment), more thorough attention to preauthorizations before admission and surgery, and more aggressive pursuit of denials to get “justice” for the patient and the facility?
While the Centers for Medicare & Medicaid Services (CMS) is trying to close the barn door in January 2024, why aren’t they looking back to bad behavior, even fraudulent, by insurers since 2014? We know they pursue providers and hospitals for clawbacks, as well as fees and penalties, and will continue to do so, going forward. It appears that we are currently too busy with basic duties to emphasize our financial benefits as well as pursue clear opportunities to gain control of our destiny.
Where would we see more bang for our buck? We continue to hear that our signed contracts represent the basic flaw perpetuating our inability to close several drains. I believe that we need to be an integral part of contracting before they are signed, and this must be the main effort of our attempts. “If we are not at the table, we are probably on the menu.” We could affect the financial drain of a short but not exclusive list of the following tasks, which are commonly discussed by executive staff:
- Improving the timeliness of preauthorizations and avoiding lack of payment if best efforts are documented;
- Obtaining binding, timely authorizations without time locks on appeal, with requested information (protect urgent and emergent as nonnegotiable);
- Defining authorization denials as practicing medicine, not negotiating payments;
- Preventing readmissions for all causes not being reimbursed, regardless of the absence of association (the heart-failure patient who is hit by a car? Or an inability to appeal unless the amount is over a threshold? Our opponent has an infinite lookback period to nitpick.);
- Setting time limits on audits from the insurer or their contracted agents to being cost-free and within six months of submitted clean claims, without using small discrepancies to continue to argue for recoupment;
- Limiting audits to one per case, not for a variety of topics;
- Limiting prolonged stays in observation and forcing the insurer to truly partner with our facilities to avoid this financial drain on their beneficiaries through copays and hospitals;
- Maintaining access to the entire appeal tree;
- Allowing batching of claims to control costs and argue variability in claim denials (as seen in a recent malnutrition settlement);
- Controlling peer reviews to identifiable physician peers;
- Limiting AI-generated denials and limiting the volume of denials to a reasonable time frame;
- Mandating adherence to CMS guidelines, though one can expect insurers trying to paint outside the regulations;
- Mandating recognition of inpatient-only lists, ambulatory exceptions criteria and Medicare exception criteria for short stays (death, hospice, transfer, against medical advice, rapid improvement). Aren’t they benefiting from the shorter stay, or the handoff to CMS for hospice?
- Improving our access to patient advocacy;
- Avoiding losing reimbursement for observation services if appeal of inpatient status is unsuccessful;
- Obtaining immediate definition of any proprietary guidelines used for denial; and
- Ensuring that any contracted item, including proprietary guidelines, cannot be changed unilaterally or without mutual approval.
By limiting the extra demands on our time created by unequal contract terms, physician advisors may have more time to pay attention to helping improve and tighten our pre-hospital authorization, our placement assistance, and more.
Until administration recognizes that our involvement during the contracting step yields dramatic benefit, physician advisors need to emphasize our contribution in compliance, especially on status, for high-weighted Diagnosis-Related Groups (DRGs) and short stays, where audits can be especially costly to facilities. Facing critics, we started a one-day billing hold for Medicare short stays. Rather than affecting timely billing, this hold allowed cleaner submissions to be produced, as seen by recent Livanta audits finding virtually no fault. While not producing money, avoiding costly audits is priceless, and should be seen by the administration as having great value.
Administration needs to only imagine that their internal experts, if properly trained and empowered, can bring value to virtually every hospital activity. Physician advisors protect the hospital against increasingly prevalent audits, prevent contracting away rights placing hospitals subservient to insurers’ whims, and optimize and preserve the billed services, maximizing hospital revenue, ensuring its mission for the future.
I’d like to leave you with my musings from 30 years ago:
and not to find,
and yet see no markers,
and have no dreams,
to close one’s eyes
and only see the dark, is to chain
oneself to the cold and empty.
who seeks everything,
who searches everywhere,
who yearns continuously,
and who can see with closed eyes
meadows of wind-swept green,
lakes of rippling blue,
and mountains of towering majesty
There lies the future of man.
Or should I add of the physician advisor.