“Doing the right things right at the right time.”
— from Malcolm Baldrige’s concept of Integrated Enterprise Excellence, the basis for The Malcolm Baldrige National Quality Award
Physician Advisor Overview
EdiPhy Advisors physician advisor services are available when you need them. Our physician advisors are trained and experienced to assist hospitals and attending physicians in examining documentation to insure support for patient status decisions (inpatient vs. outpatient), as well as facilitating complete documentation needed for compliance with health care law and CMS rules, regulations, and guidance. Training and communication for our physician advisors is ongoing, relevant and thorough.
In order to deliver excellence in medical necessity reviews and other compliance solutions, EdiPhy Advisors provides ongoing education to our physician advisors relative to health care law and regulatory guidance, as well as communication skills. EdiPhy Advisors provides the education to our physician advisors in groups and one-on-one.
The operating model for EdiPhy Advisors physician advisor services uses actively practicing board certified MDs as physician advisors. These MD physician advisors understand the challenges faced by attending physicians on a daily basis. Our physician advisors receive support from a team of experienced RNs who understand the complex criteria-based issues and the timing and certification requirements necessary to receive Medicare, Medicaid, and commercial insurance reimbursement. Leveraging our expertise and collaborative approach will strengthen your staff’s knowledge and understanding of CMS regulations and guidance in practical ways that can support the hospital’s ability to obtain correct payment for services rendered. Our physician advisors review cases concurrently to support staff in real time, or retrospectively to support internal compliance goals, including self-audits.
MD/JDs lead EdiPhy Advisors regulatory compliance and physician regulatory education efforts, thus bridging the legal and clinical chasm. EdiPhy Advisors physician advisors are board certified, and our operating model uses actively practicing physicians who demonstrate professional excellence and strong communication skills.
Concurrent Medical Necessity
EdiPhy Advisors physician advisors are “at your service” around the clock to assist with patient status decision issues, documentation and certification requirements and continued stay reviews. EdiPhy Advisors assists hospitals and other health care providers with the all-important determinations of whether patients should be classified and billed as inpatients or outpatients with or without observation services.
Timing is important for medical necessity of patient status decisions as the timing of the inpatient order determines whether a case is subject to the benchmark or presumption for Medicare billing purposes. The concurrent review process facilitates complete documentation needed for compliance with health care law and CMS rules, regulations, and guidance. The concurrent process also enables real-time feedback to client staff to ensure that documentation or process deficiencies are addressed.
Our physician advisors are also experienced with conducting peer-to-peer discussions with both attending physicians and Medical Directors of health plans, addressing Medicare medical necessity guidelines and coverage requirements for Skilled Nursing Facilities and Inpatient Rehabilitation Facilities (IRF), evaluating continued stay cases.
EdiPhy Advisors believes that actively practicing physicians are best equipped to know state of the art medical treatment protocols and can effectively use this knowledge both to document medical necessity and to communicate with practicing physicians. As such, our business model uses actively practicing physicians as physician advisors. The communication between physicians is enhanced when the physician advisor has the credibility of active practice.
EdiPhy Advisors’ team of board certified and actively practicing physicians is committed to providing physician-to-physician advisor services and to demonstrating professional excellence and strong communication skills. Our clients view our physician advisors as important pieces in their compliance and education puzzles. Equipped from their own experience with first-hand knowledge of communication barriers in health care provider organizations, EdiPhy Advisors physician advisors assist clients with strategies to improve communications in order to enhance dissemination of legal and regulatory updates. In this way and through formal medical staff education (EdiPhycation), we work to provide support for clients’ ongoing compliance efforts and initiatives.
Retrospective Medical Necessity
Whether needed to support internal compliance & quality initiatives or to respond to a government (or other 3rd party) audit, EdiPhy Advisors is a valuable resource to clients in reviewing medical records for patients post-discharge. These retrospective reviews have the potential to identify billing errors that may be either random or systemic. Once identified, EdiPhy Advisors staff is experienced in designing corrective process and/or education to correct any systemic issues identified.
Self-auditing is an important compliance initiative. Audits ensure compliance with changing regulations and provide valuable information relative to the potential need for process improvement and/or educational efforts. Audits also identify process deficiencies and weaknesses and provide a basis for ensuring integrity with revenue requirements. EdiPhy Advisors conducts audits both as part of routine compliance audits and to address special needs, such as responding to an internal complaint, question or issue that has arisen at a health care facility.