Physician Advisors: Providing Care in the Context of Regulatory Understanding

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Original story posted on: October 25, 2017

The struggle continues to foster understanding that compliance is linked to care.

Essentially every physician advisor entered the field of medicine to cure ailments, alleviate suffering, and make a difference in the world. Whether the focus was broad or concentrated on a single organ system, our passion has been and continues to be the struggle to improve the health of those we encounter.

Most of us physician advisors have no misconceptions when it comes to how other doctors view our work. We’re called quitters, deserters, sellouts – take your pick. Indeed, focusing on rules and regulations pertaining to Medicare, insurance plan billing practices, and standards in medical documentation are a far cry from our former roles at the bedsides of patients. 

The feeling physician advisors experience of having lost one’s way can be amplified by the lamentations of providers with whom we interact. “That has nothing to do with the patient,” we hear. “I didn’t go to medical school to understand medical billing.” And my personal favorite: “I’m taking care of the patients, find someone else to take care of status.” The message we often receive is clear: your work has nothing to do with helping patients.

I beg to differ.

Our expertise in governmental policy and hospital revenue cycle augments, not replaces, our original mastery of anatomy, physiology, and microbiology. Without experience as clinicians, we wouldn’t be able to assess for appropriate status in accordance with the two-midnight rule. Recognition that a prolonged hospital stay occurred due to the progression of the patient’s condition rather than a flaw in procedural scheduling would be more difficult to achieve. And we would be less capable of brainstorming ways to provide patients the care they need outside the hazards of the hospital setting. 

One of our greatest responsibilities is educating our colleagues how the work is related to patient care. Consider a dismissive view of timely status orders. If an inpatient order is not placed at 10:30 p.m. with the other admission orders, but instead at 7:30 a.m., when the case manager arrives, the patient could be significantly impacted. Three midnights in the hospital will not count toward a Medicare-covered skilled nursing facility (SNF) benefit because that inpatient order “had nothing to do with patient care.” When the patient elects to go home instead of recovering at a SNF because he or she can’t afford it, is her care impacted, then?

How about the 87 hospital closures that have occurred since 2010? While the reasons are multifaceted, physicians need to know that poor quality scores related to incomplete documentation is one factor that played a role. Another was financial loss each time an inpatient-only service was performed without an inpatient order.

Clinically speaking, is the order as important as the post-op instructions for care? Of course not. But let’s consider the patient care impact in those communities that have lost their hospitals, in part because of careless omissions such as that of a status order. 

Years ago, when I struggled to start a line on a septic infant, I did not rant that the need for IV antibiotics was “ridiculous” and created undue hardship. It simply needed to get done. The same goes in our current healthcare climate. There are constraints we live in and requirements that must be carried out, whether clinicians like them or not, for the good of our patients. 

And it’s our job to lead the way.

Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADV

Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADV, is a physician advisor for case management, utilization, and clinical documentation at ProHealth Care, Inc. in Wisconsin. Dr. Ugarte Hopkins practiced as a pediatric hospitalist for a decade. She was also medical director of pediatric hospital medicine and vice chair of pediatrics in Northern Illinois before transitioning into her current role. She is the first physician board member for the Wisconsin chapter of the American Case Management Association (ACMA), a member of the board of directors for the American College of Physician Advisors (ACPA). Dr. Ugarte Hopkins also makes frequent appearances on Monitor Mondays and is a member of the RACmonitor editorial board.

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