Case study
Using physician advisors as an agent for change
Learning objective:
At the completion of this educational activity, the learner will be able to:
- Identify the advantages and challenges of having physician advisors involved in performance improvement efforts.
Physician advisors (PA) are an important ally for case managers at many organizations when it comes to ensuring proper patient status. But one organization has greatly expanded the role of PAs to include performance improvement and as a result has seen improvements in everything from readmissions to length of stay.
Ven Mothkur, MD, MBA, LSSBB, the corporate physician advisor at the Franciscan Alliance, a 14-hospital health system based in Illinois and Indiana, says that the organization shifted from an outsourced group of PAs to an internal team of 13 PAs and five physician clinical documentation improvement (CDI) specialists over a one-year period in 2014.
"I think we’re quite traditional in some respects," he says. "The primary function of the PAs is to perform patient status reviews. But what makes the role unique is its emphasis on the PA as a leader in performance improvement."
In the past, PAs at the organization were very much in figurehead roles. That has since changed dramatically. Today, PAs at the health system are still visible leaders but are also engaged, active full-time staff members that serve as a bridge between the medical staff, case management, and the C-suite.
The PAs run daily interdisciplinary rounds and are essentially the physician representative for case management and utilization review, but they are also liaisons between the chief medical officer (CMO) and the chief financial officer (CFO), helping to translate corporate goals into actionable plans. This includes global efforts to improve continuity of care and work as part of multiple accountable care organizations.
When an issue crops up, the PA’s are in a position to investigate the challenge. For example, if the observation rate starts creeping up they may jump in and start asking questions.
"What’s happening on the ground? Is it an issue with a payer? Are they being too delayed in getting back with authorizations? Is it a delay in communication between the attending physicians and case managers? Is it a delay on the end of the physician advisor getting back?" says Mothkur.
This new, "mid-revenue cycle" position allows the PAs to focus on what’s going on in the organization as a whole and help make performance improvements in response.
The health system implemented the new PA program after looking at its outsourced PAs and the value they were bringing to the organization. "When we looked at the cost to benefit ratio, it was just not there," says Mothkur.
The health system realized that there may be a real benefit to having well-respected members of the medical staff take on this role working alongside their colleagues.
Today, the PAs at Franciscan Alliance perform regular status reviews and ensure that the hospital is running a tight ship on the front end, but they also keep an eye on all the organization’s dashboards, metrics, and trends and turn those numbers into performance improvements.
Making the shift to the new model required a multi-step process that began by taking a good look at the organization and its needs.
Below are the main steps an organization will need to take to begin a similar program.
Shifting the role of the PA
Step 1: Financially justifying the change. The most challenging aspect of allowing PAs to shift their focus is justifying the change to upper management. "You have to give as much of a financially justifiable ROI as possible to the CFO. They’re the ones who approve it," says Mothkur.
When analyzing data to determine whether changing the focus of PAs, consider all the soft returns on investment, such as decreases in the observation rate, fewer denials, more medical staff engagement, or a higher case mix index, he says.
Step 2: Assessing the need. What are the problems your organization wants to address and will they be best solved by a wholly internal group of PAs or a hybrid model?
Some organizations use internal PAs during the week and switch to outsourced PAs to handle calls on nights and weekends, says Mothkur.
"I think the first step in doing this is to look at where you have huge gaps," he says. One starting point might be to look at the organization’s gross revenue write-offs. If this number is beyond national benchmarks, there may be an immediate and readily apparent benefit to having PAs move in and address the problem areas you find.
Also look at your mix of physicians. Are they primarily employed or independent? It may be easier to gain compliance from employed doctors with educational initiatives while independent physicians may require more intervention from PAs to accomplish the same goals.
Also look for other areas that could use improvement. For example, if your denials are high then your observation rate is high, or you are having trouble with payers then PAs can help smooth over some of these problem areas.
The PAs at Franciscan Alliance have become the oil that keeps the machine humming. If the oil was not there, the machine wouldn’t be operating as effectively. "There are now gaps that are picked up, there is improved compliance, nurses are happier, CM is ecstatic, the CFO has answers to what they’re seeing in numbers, the CMO has a second in command," says Mothkur.
Step 3: Choose the right PA. Finding the right person to fill this challenging role can be difficult. "It’s a matter of identifying the right person who is willing to do it all," says Mothkur. But this person also has to be someone who has the respect of the medical staff, someone who is ready to move on from practicing medicine daily to an administrative role and is excited about the opportunity to make improvements at a hospital level.
This job is not for the physician who took the opportunity in the past to scale back and work remotely, he says.
"Our PAs have to come to the hospital, attend leadership meetings, sit in the medical staff office for lunch, just to be there," he says. "This is very much a full-time job. The docs that we’ve gotten into it say it’s harder than clinical practice."
Often the PAs work 50 hour weeks. They also have to have thick skin, because they need to push back against their peers in some instances.
"It’s hard to find someone like I just described," says Mothkur.
To make its selections, Franciscan Alliance asked the CMO, among others, to identify potential candidates who were well respected, possessed leadership qualities, and were potentially interested in leaving clinical practice. Also look for physicians who have an appetite for looking at data and analyzing numbers.
Step 4: Ensure proper training. Once candidates are identified, training should begin as quickly as possible, says Mothkur. In the absence of formal training programs, organizations often have to cobble together their own programs, which should involve the following:
- Getting the candidate introduced to and embedded in the case management and CDI departments.
- Linking PA with educational resources, such as professional organizations like the American Case Management Association, Case Management Society of America, ACDIS, or the American College of Physician Advisors.
- Ensuring familiarity with different payers and health plans and ensuring proper education on InterQual® and MCG® (formerly Milliman) standards.
- Encouraging PAs to attend conferences on related topics and to join industry list-servs where PA topics are discussed. "The training is really very much on-the-job training, learning as you go," says Mothkur.
Step 4: Follow up. After the initial adjustment period, determine how the PAs are performing by polling case management and other departments, including the medical staff. Don’t be surprised if the medical staff is a little agitated by PAs, after all the job can be and should be a little adversarial.
The relationship between case management and PAs should always be one of mutual respect. A good PA will have respect and empathy for the increasingly complex and evolving case management role. A PA should have the attitude of "how can I help you," says Mothkur.
"There is often a shared bonding [between the PA and case management] over war stories because you’re fighting the same payers," he says.
A functional and positive relationship can pay dividends.
Franciscan Alliance has not only saved money by using an internal group of physicians. The other benefits of this approach include a reduction in the following:
- Denials
- Inappropriate admissions
- Avoidable days
- Readmissions
- Observation length of stay
- Overall length of stay
And case management has an important ally to support them and to help drive organizational change. "For case management it’s about knowing they have this leader and champion standing behind them that they never had," says Mothkur.
NOTICE Act confusion continued into the summer
Learning objective
At the completion of this educational activity, the learner will be able to:
- Identify challenges related to the lack of information about the Medicare Outpatient Observation Notice and the Notice of Observation Treatment and Implication for Care Eligibility Act.
Hospitals were struggling this summer to comply with the Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act, which was signed by President Barack Obama August 6, requiring hospitals to provide a verbal and written notice of outpatient status to any patient in observation who has been in the hospital for more than 24-hours.
With only a preliminary form on the PRA website to guide them (http://ow.ly/7TPE302eSiM), many organizations were finding more questions than answers in their quest to comply with the regulation.
"[The preliminary form] does not have an Office of Management and Budget approval number, so it is not finalized," says Ronald Hirsch, MD, FACP, CHCQM, vice president of the Regulations and Education Group at Accretive Health in Chicago. "And there are several comments that it is not written to the federal standard for understanding by someone with limited education, so it may not even be approved in its present form. CMS has also said they will give further guidance on the requirement for verbal explanation so it is hard to know who will be allowed to present and explain the form."
In July, Janet Blondo, MSW, LCSW-C, LICSW, CMAC, ACM, CCM, C-ASWCM, ACSW, the manager of case management at Washington Adventist Hospital in Takoma Park, Maryland, was still looking to have a number of questions about the rule answered.
"I contacted the Maryland Hospital Association who researched this issue," she says. "The staff at MHA are conferring with experts at the Maryland Department of Health and Mental Hygiene about my questions and concerns and expect to have a response soon."
This lingering uncertainty not only was making it difficult for hospitals to start planning for compliance, but also led some to speculate that the compliance date would be extended.
The Ohio Hospital Association (OHA) in June told its members that the requirement date could be pushed back until October.
"The implementation of the Medicare Outpatient Observation Notice, or MOON, was set for August 6, 2016. However, as hospitals await the details of the federal fiscal year 2017 inpatient prospective payment system final rule, CMS is now stating that the MOON requirement date may be pushed back to October. Stay tuned for a final decision on the MOON implementation date," the OHA stated in a written release (http://ow.ly/z0qZ302fmvH). But as of mid-summer this talk still amounted to unsubstantiated rumors, says Hirsch.
"Unless someone knows someone at CMS, there is no official word. I did read many of the comments to the rule and many asked for a six-month delay. My guess is that they cannot delay the implementation since it is a law but they will delay enforcement for three months," he says.
In the meantime, organizations were trying to do what they could to get ready.
The NOTICE Act stipulates hospitals must inform patients within 36 hours from the start of the service, or at the time of discharge, about their status.
The goal of the legislation is to ensure patients are aware of their status and what it might mean for them financially?in particular, how it might affect their post-acute care options.
Patients often (wrongly) assume that if they’re in a hospital bed, they are an inpatient.
They also don’t understand the implications of outpatient billing status.
One of the biggest issues that can crop up when a patient’s care orders place him or her on observation status is that he or she will not be eligible for Medicare coverage for a post-acute stay in a skilled nursing facility (SNF), and instead may need to pay more out of pocket. Medicare currently only covers SNF extended care rehabilitation services for patients who have three consecutive inpatient days in a hospital. For example, one day in observation and two days as inpatient equals three days in the hospital, but does not meet the three-day inpatient day stay requirement because it only includes two inpatient days.
"An Office of Inspector General report found that the average out-of-pocket cost for SNF services not covered by Medicare was more than $ 10,000 per beneficiary," states a press release issued by the congressional leaders who promoted the bill (http://ow.ly/S6JSB).
To comply with the rule, hospitals will now need to designate someone?in some cases it may be the case manager?to provide this notification.
Stefani Daniels, RN, MSNA, ACM, CMAC, founder and managing partner of Phoenix Medical Management, Inc., in Pompano Beach, Florida, says a few of her clients were trying to get the form included in a packet of admission papers that are given to each Medicare patient to sign.
But even so, as of press time most organizations had more questions than answers about compliance. Stay tuned for updates in future issues of CMM.
Ask the expert
Understanding nuances of patient status and therapeutic services
Learning objective
At the completion of this educational activity, the learner will be able to:
- Identify strategies to comply with condition code 44 and the Medicare Outpatient Observation Notice (MOON), and understand rules related to some aspects of therapeutic services.
Assigning the correct patient status is a constant challenge for hospitals and the case managers who are charged with ensuring these decisions are accurate. CMM often gets questions from readers on related topics and we forward them to our experts to get the answers. This month’s questions were answered by Ronald Hirsch, MD, FACP, CHCQM, vice president of the Regulations and Education Group at Accretive Health in Chicago.
Q: If a Medicare patient is downgraded from inpatient to observation is it expected that the patient will be issued the MOON and condition code 44 will be used on the claim?
A: First, it must be noted that all patients who are downgraded using the condition code 44 process are being downgraded from inpatient status to outpatient status. If the patient then needs continuing hospital care (i.e., is not ready to be discharged), then observation can also be ordered. If observation is needed and is ordered, the MOON will be required only if the patient receives observation for 24 or more hours from the time of this order for observation services.
Q: I have a question about how to interpret the CMS Standard Operating Procedures. If a requisition/order for physical therapy treatment is received at a hospital facility and is not authenticated (e.g., signed, timed, dated) by a community physician who is not credentialed at the hospital, is it true that facility can begin treatment but the order must be authenticated when it will be filed in the record?
A: Therapy services (e.g., physical, occupational, speech-language pathology) are unique in that an actual order from a physician or non-physician practitioner is not required (see the Medicare Benefit Policy Manual, Chapter 15, Section 220.1, at www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf). The following is required:
- The patient must be under the care of a physician
- The therapy must be provided under a plan of care
- The physician must certify that plan of care by way of signature and date
In this case, the therapy provider may develop a plan of care and forward it to the physician for certification. Treatment may begin while awaiting the return of the signed plan of care. But the organization staff should do their best to get the signed certification returned within 30 days of start of therapy services.
Because the physician is not on the medical staff, the therapy provider may want to confirm that the physician is enrolled with Medicare and therefore eligible to order and certify services on Medicare recipients.
Got a question on any case management topic that you’d like to ask our experts? Email it to Kelly Bilodeau at [email protected].
Bonus question
Q: What do you do with a patient who does not have a safe discharge plan, but does not meet inpatient criteria and has been in observation status for 48 hours?
A: The original instruction from CMS that still stands is that we give the patient an advance beneficiary notice that says his or her care in the hospital setting is no longer medically necessary and is not being billed to Medicare and that he or she will be financially responsible.