New Physician-to-Physician Support for Bed Status Decisions

 By Peggy Mark, chief nursing officer, Premier Health; and Matthew Reeves, DO, vice president – integrated care management, Premier Health

It’s our pleasure to announce the debut today of a new physician-to-physician tool across Premier Health, with an eye toward providing an additional layer of support for administrative and regulatory concerns that require physician action.

Through Physician Advisor (PA) On-Call, a team of physician advisors will now remotely support Premier Health physicians in determining, for example, whether a patient should be designated as an inpatient, observation, outpatient in a bed, etc. While physicians are responsible for making these determinations per Conditions of Participation with CMS, Premier Health also recognizes that these are complex medical judgments that often benefit from readily available peer input. The advice, education and support provided by these physician advisors via phone should significantly reduce the number of follow-up phone calls that physicians receive to clarify their documentation, and we anticipate that these physician advisors will become familiar and trusted resources for our doctors in carrying out their review activities for integrative care management (ICM), Center for Status Integrity (CSI), and clinical documentation improvement (CDI).

The addition of the PA On-Call program does not replace CSI. It should, however, eventually reduce the need for CSI outreach to physicians. Over time, our goal is to move the program in-house, providing at least one physician advisor at each Premier Health hospital and bringing this resource to the floors at the time of need.

This additional service is expected to have a positive effect on the patient experience, length of stay and denials while enhancing regulatory compliance.

The service will initially be available from 10:00 am to 5:00 pm on weekdays, as well as from 8:00 am to 6:00 pm on weekends if the need is time-sensitive. CSI will continue to be available around-the-clock.

Physicians may call the new PA On-Call service at 1 (844) 438-7262, x7485, or (937) 598-2954.

PA On-Call Q&As

Q) What is a physician advisor (PA)?

A) A PA provides advice, education and support to processes related to the medical necessity of services as part of the ICM and Center for Status Integrity (CSI) review activities as well as CDI. Key elements include:

• Advising
• Consulting
• Teaching
• Analyzing

Q) What specific types of support does a PA provide?

• Secondary concurrent chart reviews for medical necessity and status determination
• Concurrent denial management/peer-to-peer calls
• Assists in denials and appeals processing
• Clinical documentation improvement education
• Utilization management support (length of stay, resource use, patient flow)
• Regulatory expertise
• Compliance partner
• Quality improvement and patient safety efforts
• Patient experience efforts
• Patient financial assistance programs
• Medical staff, administration liaison and education efforts
• Liaison to payers and their medical directors, often building close working relationships

Q) How would a PA interact with me on a day-to-day basis?

A PA will likely interact with you through ICM, CSI, or a direct peer-to-peer phone call. A PA should be able to assist you with these activities:

• Case management support
• Unit huddles
• Discharge planning
  • patient/family care conferences
  • readmissions
  • patient flow/transfer

Q) Why are we creating this program

• Quality benefits
  • Dedicated clinical input at the physician level to make process improvement efforts more effective
  • Enhanced standard of care through “lessons learned” education (from audit and denial lessons)
  • Reduced length of stay and readmissions
  • Additional operational benefits
• Appropriate medical necessity and status determinations
  • Reduction of uninsured cases
  • Reduced concurrent inpatient denials
  • Reduced pre-payment, RAC and other recovery audit denials
  • Appropriate severity of illness, mortality, and case mix index
  • Improved resource utilization
  • Improved HCAHPS and other value based reimbursement model metrics
  • Improved physician support

Q) Will PAs only be available by phone, or will they be physically present in the hospitals as well?

A) Over time, we expect to have at least one PA in person at each facility. This will mean “boots on the ground” in your huddles.

Q) When did the PA On-Call Service begin?

A) Wednesday, September 12, 2018 

Back to the September 2018 issue of Premier Pulse