Click Here to download the 2012 Educational Seminar Catalog                                   Click here to sign up!

The Physician Advisor Certified in Clinical Documentation Improvement & Integrity Specialist is a physician serving the hospital through teaching, consulting, and advising both the case management/utilization review department and the hospital on matters regarding physician practice patterns, over and under-utilization of resources, medical necessity, levels of care, care progression, denial management, compliance with governmental and private payer rules and regulations, and working in collaboration with payers and the community. The Physician Advisor is a key member of the organization’s leadership team charged with meeting goals of cost and quality of care. 

The Physician Advisor acts as a liaison to the Medical Staff for Case Management/Utilization Review operations and conducts clinical reviews on cases referred by Case Management (CM) staff and/or other healthcare professionals, in accordance with the hospital’s established Utilization Management (UM) Plan.  The Physician Advisor meets the hospital objectives for assuring quality patient care and effective, efficient utilization of health care services.  

Overall Program Learning Objectives:

• Define Medicare Conditions of Participation and the Utilization Review (UR) Committee
  • Physician Advisor (PA) and the UR Committee involvement
  • Chair, co-chair, educator or facilitator
• Extensive knowledge of Medical Necessity appropriateness
  • Admission
  • Continued stay
  • Discharge parameters
• Understanding Severity of Illness (SI) and Intensity of Service (IS) Guidelines
  • Identify and assist with compliant documentation of severity of illness as it relates to disease pathophysiology and acuity for the hospitalized patient
  • Identify and demonstrate knowledge related to treatment modalities directly related to severity of illness and assist with the appropriate relationship between appropriateness of disease and standard treatment plans (for over-utilization and under-utilization of resources)
• Define an Inpatient Admission and help the Case Manager’s (CM) identify compliant physician documentation necessary for the inpatient admission
• Define an Outpatient Observation Service and identify hospitalized patients whose diagnosis and treatment plan meet medical necessity for outpatient observation services
• Define extended Post-Operative care not appropriate for observation services and assist the CM’s to determine appropriateness
• Condition Code 44
  • When an inpatient admission for a Medicare beneficiary does not meet medical necessity for inpatient admission and the attending physician agrees
• Physician to physician case reviews
  • UR Committee decision
  • Concurrent discussion of cases where care does not meet nationally recognized or facility supported standards of care
• Peer to Peer review to third party payers
• Physician discussion with the insurance companies is needed to medically support the level of care and treatment for an inpatient to prevent a potential denial
• Assisting with written appeal processes when required by the UR Committee
• Hospital Issued Notices of Non-Coverage
  • Pre-Admission/Admission–Determination assisted by PA when SI and/or IS does not support patient admission
  • HINN-10 (Hospital Requested Review)-Determined by PA support when IS is not met for continued stay and the attending does not agree
  • HINN-12 (Continued Stay Review)-Determined with assist of the PA when attending refuses to discharge a patient that does not meet medical necessity for IS after HRR is returned by QIO 
• Review of Medicare One Day Stays after discharge for Provider Liability

Attendees have the option of taking the Certification Exam within 6 weeks of this Program.

For more information about our programs contact:

Jim Lewis

757-695-4995

JLewis@DocucompLLC.com