In January 2012, I became our hospital’s first full-time physician Advisor. I was tasked with three duties: write appeal letters, do status reviews, and chair our UR committee. Having written my own job description, I also started working on processes to improve our average length of stay (ALOS) of both admissions and observations. Trying to establish an effective ALOS improvement process was initially a muddle. 

Then in March of 2012, I attended a lecture, "Multidisciplinary Rounds," presented by Dr. Howard Stein the physician Advisor at CentraState Medical Center in New Jersey, ACPA Board member, and a national expert on physician Advisor multidisciplinary rounds. It was a career changing lecture that unmuddled me. I returned to our hospital and instituted the Delaware version of Jersey rounds. 

On the RAC-Relief user group, a physician advisor asked for advice on a recurring problem in her institution concerning patients and chemotherapy at the end of life.

The patient was an elderly gentleman with two primary cancers (lymphoma and lung) who was admitted with hemoptysis and obstructive pneumonia. The patient was told by an outside facility at university cancer center that his cancer is incurable but reportedly he "wants to continue the fight." The local oncologist ordered chemotherapy. As the physician advisor, he wrote, "discussed the futility of treatment and he is adamant that it is necessary for palliative purposes. The following morning, the patient has large episode of hemoptysis, codes and after brief resuscitation and intubation, the family requests comfort care only and passes away."

Here is the advice I gave her:

We have all been faced by these situations and there are many articles written about patients getting chemo during their last moment of life. I have found it is based on the doctor's religious/philosophical/economic view of life rather than the patient's. Some docs thinks it is murder to not try anything and everything (yes, one doc called me a murderer for confronting him in a situation like this), some believe in miracles, and some just want to harm the hospital by burdening them with the costs. Universally all these cases were with doctors whose communication skills with families were poor; they never asked what the patient wants. I find the person most traumatized is the RN that cared for the patient and was forced to administer the chemo. They rank it up there with giving Dilaudid to a drug seeker as the most unsatisfying part of their job (we sure worry about patient satisfaction; maybe thinking of employee satisfaction would also be a good idea.). Of course the patient ends up getting the treatment and dying; I wait a week or so then talked to the doc about it and explained the availability of hospice and the ethics committee. (We did not have palliative care at the time.) I wanted to start the conversation with "I told you so!" but I resisted and say "things did not work out for Mrs. Smith. I hope you realize that I was being a patient and a hospital advocate and was not trying to deprive a patient of necessary care." 

And finally, some of the most rewarding experiences I have had was when I told my patients that I thought it was time to stop chemo and work on the quality of the life they have remaining. Universally, I was thanked for being the first doctor to tell them what they really wanted to hear; they were tired of "we can try one more drug" because they knew it was not going to work.

The landscape of healthcare is in the midst of significant change, most physician advisors will agree. We hear the word “unsustainable” a lot these days – whether referring to healthcare’s percentage of US GDP, patients’ co-insurance and premium increases, shrinking hospital margins, rising pharmaceutical costs, the volume of the ALJ appeals backlog, or even (not so long ago) maximum RAC ADR requests hammering hospitals’ administrative resources.

The growth in the number of physician advisors in the past 10 years has been in large part due to the “level of care” decision. Is this hospital visit an outpatient encounter, outpatient with observation service, or inpatient? In 2005, the Hospital Payment Monitoring Program published guidance that Medicare cases should be screened for proper level of care and referred for secondary physician review if there was a mismatch between the screening criteria and the ordered level of care. The usage of screening criteria and physician advisor services became widespread and commonly accepted during that decade for this and other reasons.

Those of us hoping the Centers for Medicare and Medicaid Services (CMS) would change course under the barrage of criticism of the 2-midnight rule coming from the American Medical Association, the Society of Hospital Medicine, the Medicare Payment Advisory Commission and a wide variety of industry critics (including this writer) were disappointed that the 2-midnight rule remains intact in the 2015 Outpatient Prospective Payment System (OPPS) proposed rule (CMS-1633-P).

CMS has moved responsibility for auditing short inpatient stays from the Medicare Administrative Contractors (MACs) to the Quality Improvement Organizations (QIOs). While QIOs have experience in reviewing medical necessity for hospital services (including admissions) they have done this on a limited basis. One can’t help but wonder how they will prepare for a high volume of reviews by the proposed start date of October 1, 2015. Might the quality of their work deteriorate to the level of the Recovery Auditors (RACs)? CMS has directed the QIOs to review "a sample" of cases but the proposed rule gives no clue if there will be defined limits on additional documentation requests (ADRs) and what the ADR limits might be. The QIOs will report to the RACs those hospitals with a high level of billing errors and RAC reviews will be limited to these hospitals. RAC ADR limits will vary depending on the size of the hospital, its record of billing errors, and its response to QIO education efforts.

A few years ago, I found myself spending my days and nights reviewing charts while working with highly trained interventional cardiologists, hospital compliance officers, hospital attorneys and outside counsel from around the county in order to assist in their defense in the Department of Justice's (DOJ) national investigation on implantable cardiac defibrillators (ICDs).  The focus of the investigation was the requirements for billing for the implantation of an ICD according to national coverage determination (NCD) 20.4; the DOJ was concerned that hospitals and physicians did not adequately follow the NCD requirements when billing Medicare for ICD implantation. The hospitals and physicians contended that the NCD was outdated and it would have been malpractice if they were to have followed the requirements.  The DOJ took the position that they were not attempting to direct patient care but that hospitals and physicians were noncompliant since chart documentation did not meet the Medicare criteria for coverage.  For example, some charts were lacking documentation of an ejection fraction that was less than 35% or that the patient had ventricular tachycardia but it was not clear if it was sustained or if the patient was symptomatic.  These are just two examples of potential violations from the very complex resolution model created by the DOJ for this investigation. The investigation is still ongoing. 

I also assisted in the defense of a solo practice rheumatologist who was being asked to repay almost two million dollars (including damages) because she did not document the clinical need for Remicaide adequately per the requirements of LCD 25820 for Infliximab (Remicaide).

The reason for bringing up these investigations is a rather simple one.  I wonder how many practicing physicians out there are aware of the national and local coverage determinations (NCDs and LCDs) with which they are obligated to abide?  How many physician advisors are aware of the myriad NCDs and LCDs which their hospitals need to follow in order to have a compliant billing process and the documentation physicians need to provide to ensure compliant billing? 

According to an article published online by Modern HealthCare on April 28, the Senate Finance Committee has taken note of the massive backlog of appeals of Medicare payment denials and has proposed some fixes, including separating the clinical appeals from the technical ones and sending technical appeals to the Medicare Administrative Contractor (the MAC) and clinical appeals to the Qualified Independent Contractor (the QIC).

This sounds like a good idea, but I'm dubious about continuing to rely on the QIC because it has a history of rubber stamping MAC denials - resulting in the log jam at the Administrative Law Judges (ALJs) and contributing to the high ALJ overturn rate. The behavior of the QIC itself should be scrutinized before giving it more responsibility and power. 

Senator Wyden's proposal to charge a provider a refundable fee to appeal seems to be an impediment to due process. Hospitals already have to pay for the appeal itself, which could include third party appeals contractors and legal fees. It's especially unattractive to propose such a fee when there is no penalty to the RAC, MAC, or QIC for an unjustified denial that's subsequently overturned by the ALJ.

The American College of Physician Advisors (the ACPA) is a non-profit professional organization supporting physicians who choose the newly emerging medical specialty of physician advisor. The ACPA was founded in 2014 and has grown rapidly to over 200 physician and non-physician members.

The organization’s primary goal is the enhance the realm of the physician advisor through education, mentorship, and professional leadership, while increasing the recognition by hospital administrators of the critical role physician advisors play in enhancing and protecting revenue. It plans ultimately to bring to physician advisors the recognition and status associated with a new medical specialty.

Medstar Health is a healthcare system that spans central Maryland and the District of Columbia.  As Physician Advisor for MedStar Good Samaritan Hospital, I am so proud of Medstar Health and how our system of 10 hospitals has been able to manage capacity and redeploy personal and equipment during this pandemic.  We recently discharged our 1000^th COVID-19 patient as a system and I would like to share highlights on how we have achieved successful outcomes.

Our COVID-19 preparations and response are guided by three critical drivers: