September 30, 2015

The Rejzer/Glaser Principle: Focus Appeals Utilizing One Physician’s Expertise

By


Ronald J. Rejzer, MD


David Glaser, Esq.

What’s the best way to use physicians in Medicare appeals?  Is it better to use one physician to testify for all of the appeals, or is it more effective to use the attending physician for each case? 

People sometimes joke about the relationship between physicians and lawyers, but on this point Ronald J. Rejzer, MD, senior vice president and chief physician advisor at Parkland Health & Hospital System in Dallas, Texas, who serves as president of the American College of Physician Advisors, and healthcare attorney David Glaser agree. 

Together they have coined the “Rejzer (pronounced “Razor”)/ Glaser principle,” suggesting that the most efficient method for both administrative law judge (ALJ) and commercial appeals is to train one physician on the appeal process and use that physician consistently to provide medical support, rather than using testimony from the attending physician.

 “Relying on an overburdened random attending physician who has little interest in sparring with the third party carriers let alone understanding the nuances of the regulations, will be less likely provide the in-depth support and assistance needed to create successful appeals,” said Rejzer. “Physicians who have the experience, expertise in appeals management and appreciation of the appeal process will undoubtedly have an advantage over the unaware and often disinterested attending physician.” 

There are some arguments for using the treating physician, suggests Glaser, a shareholder at the law firm of Fredrikson & Bryon in Minneapolis.  The treating physician will inherently have a bit more knowledge about the details of the case and may mean that he or she will also have more clinical credibility.  

“There is even an infinitesimal risk that a judge will refuse to accept testimony from someone who didn’t actually treat the patient,” said Glaser.  “Under the formal rules of evidence is in court, if the physician didn’t treat the patient the physician would need to qualify as an expert, because any testimony about the facts would be hearsay. 

Glaser, however, is quick to point out that the rules of evidence don’t apply to ALJ hearings.  

“Practically speaking, administrative law judges generally expect one physician to testify,” said Glaser. “We haven’t seen judges discount testimony of a non-treating physician, let alone refuse to accept the testimony.”

Rejzer recommends that you request the opinion of a specialist for specific expertise when crafting the first or second level of appeal letter.  

“The attending physician or specialist can successfully be involved in the requested peer-to-peer conversations at the time of the initial denial when the clinical information is fresh on their minds,” said Rejzer. “Remember that to succeed at these hearings you want to communicate effectively and concisely.  Making things easy for the judge increases the odds you will prevail.” 

Glaser believes that if you work with one physician, the physician can learn from each hearing.  Every case is likely to go better than its predecessor, he suggests. 

“The individuals who prepare the records can learn the physician’s preferences and organize the chart accordingly,” said Glaser.  “Your counsel can anticipate how the physician will react.  In short, there will be far more predictability.”     

A corollary of the Rejzer/Glaser principle is that a team approach is the key to successful appeals. 

“I recommend using the recovery auditor contractor (RAC) appeal nurse coordinator, the experienced physician advisor or medical director of case management and the hospital’s legal counsel who is also experienced and familiar with the ALJ process,” Rejzer explained.  “Asking the experienced physician advisor to review the case even before the initial review can be a worthwhile effort.  If the physician advisor is not comfortable defending the case, it may be better to avoid appealing it.” 

“Choosing cases wisely maintains your credibility, which may help increase the odds that you will prevail in cases,” Glaser added. “We both endorse the idea of choosing your cases carefully. In addition, there is no point wasting resources on a case the physician isn’t comfortable defending.  Using the same physician will allow that physician to use past experience to evaluate the strength of the current case.”  

According to Rejzer, the bottom line is that the benefits of utilizing a single experienced physician advisor throughout the appeal process and providing that physician with strong support from a consistent team, improves the odds your appeal will succeed.   

About the Author

Chuck Buck is the publisher of RACmonitor and the program host of Monitor Mondays.

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cbuck@panaceainc.com

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Chuck Buck

Chuck Buck is the publisher of RACmonitor and is the program host and executive producer of Monitor Monday.

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