National Physician Advisor Conference...National Physician Advisor Conference NPAC2019 Bridging the...

29
BRIDGING THE GAP BETWEEN CONFUSION AND CLARITY IN HEALTHCARE National Physician Advisor Conference NPAC2019

Transcript of National Physician Advisor Conference...National Physician Advisor Conference NPAC2019 Bridging the...

Page 1: National Physician Advisor Conference...National Physician Advisor Conference NPAC2019 Bridging the Gap between Clinical Documentation and Safety Scores: Expanding the role of the

BRIDGING THE GAP BETWEEN CONFUSION AND CLARITY IN HEALTHCARE

National Physician Advisor ConferenceNPAC2019

Page 2: National Physician Advisor Conference...National Physician Advisor Conference NPAC2019 Bridging the Gap between Clinical Documentation and Safety Scores: Expanding the role of the

Bridging the Gap between Clinical Documentation and Safety Scores:Expanding the role of the Physician Advisor

Nate Henderson, DO CPE FACPDirector, Clinical UtilizationAssociate Medical Director, Hospital MedicinePrisma Health-MidlandsColumbia, South Carolina

Page 3: National Physician Advisor Conference...National Physician Advisor Conference NPAC2019 Bridging the Gap between Clinical Documentation and Safety Scores: Expanding the role of the

• Brief history

• Physician Advisor (PA) value locally

• PA Process to HIM and CDI

• PA Value to CDI

Agenda

Page 4: National Physician Advisor Conference...National Physician Advisor Conference NPAC2019 Bridging the Gap between Clinical Documentation and Safety Scores: Expanding the role of the

• Locally owned, nonprofit integrated health care system

• Hospitals (1,639 beds)• Baptist• Baptist Parkridge• Children’s Hospital• Heart Hospital• Richland (Level 1 Trauma)• Tuomey

• PH USC Medical Group ambulatory practices

• 1,000 Physicians and 500 Advanced Practice Providers

Prisma Health–Midlands (formerly Palmetto Health)

Prisma Health Baptist Parkridge, Opened March 2014

Page 5: National Physician Advisor Conference...National Physician Advisor Conference NPAC2019 Bridging the Gap between Clinical Documentation and Safety Scores: Expanding the role of the

A Brief History

Page 6: National Physician Advisor Conference...National Physician Advisor Conference NPAC2019 Bridging the Gap between Clinical Documentation and Safety Scores: Expanding the role of the

• Established internal Physician Advisor (PA) program 11/1/15 for second level review

•Added PA, Denials & Appeals 10/1/16

A Brief History

Page 7: National Physician Advisor Conference...National Physician Advisor Conference NPAC2019 Bridging the Gap between Clinical Documentation and Safety Scores: Expanding the role of the

• > 3400 Medicare 2nd level reviews in FY 18• General structure of program/overview

• $2M in cost savings to Prisma Health Midlands

Physician Advisor ROI

Page 8: National Physician Advisor Conference...National Physician Advisor Conference NPAC2019 Bridging the Gap between Clinical Documentation and Safety Scores: Expanding the role of the

• General Program Structure Overview

• 500 cases reviewed FY 18• 340 Peer to peer calls

• $1.4M returned as a result of Appeals work in FY 18

(and counting)

PA Appeals Specialist & ROI

Page 9: National Physician Advisor Conference...National Physician Advisor Conference NPAC2019 Bridging the Gap between Clinical Documentation and Safety Scores: Expanding the role of the

• A task from the CFO

• Understanding the needs of HIM/CDI

• Building a business case• Who has a need for a Physician Reviewer?

Entering the CDI world

Page 10: National Physician Advisor Conference...National Physician Advisor Conference NPAC2019 Bridging the Gap between Clinical Documentation and Safety Scores: Expanding the role of the
Page 11: National Physician Advisor Conference...National Physician Advisor Conference NPAC2019 Bridging the Gap between Clinical Documentation and Safety Scores: Expanding the role of the

Are these PSIs real? What is a PSI?

Page 12: National Physician Advisor Conference...National Physician Advisor Conference NPAC2019 Bridging the Gap between Clinical Documentation and Safety Scores: Expanding the role of the

Leapfrog and PSI

Page 13: National Physician Advisor Conference...National Physician Advisor Conference NPAC2019 Bridging the Gap between Clinical Documentation and Safety Scores: Expanding the role of the

Leapfrog and PSI

Page 14: National Physician Advisor Conference...National Physician Advisor Conference NPAC2019 Bridging the Gap between Clinical Documentation and Safety Scores: Expanding the role of the

Leapfrog and PSI

Page 15: National Physician Advisor Conference...National Physician Advisor Conference NPAC2019 Bridging the Gap between Clinical Documentation and Safety Scores: Expanding the role of the

CMS Star Rating and PSI

Reporting Period for January 2019 CMS Star Rating

Domain

Domain

Weight

(%) Metric/Measure Q2

'14

Q3

'14

Q4

'14

Q1

'15

Q2

'15

Q3

'15

Q4

'15

Q1

'16

Q2

'16

Q3

'16

Q4

'16

Q1

'17

Q2

'17

Q3

'17

Q4

'17

Q1

'18

Lag

Time

COMP-HIP-KNEE 4-5 years

PSI-90-SAFETY 3-4 years

HAIs 1-6 2-3 years

AMI, CABG, COPD, HF, PN, STK 4-5 years

PSI-4-SURG-COMP 3-4 years

CABG, COPD, Hip/Knee, STK

EDAC: AMI, HF, PN 4-5 years

HOSPITAL WIDE 2-3 years

OP-32 1-2 years

Patient

Experience22% H-COMP 1,2,3,5,6,7,

Clean, Quiet, Rating, Recom 1-2 years

Efficient Use of

Medical Imaging4% OP-8,10,11,13,14

2-3 years

OP-22,29,30,33 1-2 years

OP-4,23,PC-01,SEP-1,VTE-6 1-2 years

IMM-2,3/OP-27 1-2 years

Timeliness of

Care4% ED-1b,2b,3

OP-1,2,3b,5,18b,20,21 1-2 years

4%

Readmission

(30 Day)

22%Safety of Care

22%Mortality

22%

Effectiveness of

Care

Page 16: National Physician Advisor Conference...National Physician Advisor Conference NPAC2019 Bridging the Gap between Clinical Documentation and Safety Scores: Expanding the role of the

Entering the CDI world

Page 17: National Physician Advisor Conference...National Physician Advisor Conference NPAC2019 Bridging the Gap between Clinical Documentation and Safety Scores: Expanding the role of the

Entering the CDI world

Page 18: National Physician Advisor Conference...National Physician Advisor Conference NPAC2019 Bridging the Gap between Clinical Documentation and Safety Scores: Expanding the role of the

Mapping it Out

Page 19: National Physician Advisor Conference...National Physician Advisor Conference NPAC2019 Bridging the Gap between Clinical Documentation and Safety Scores: Expanding the role of the

Mapping it Out

Page 20: National Physician Advisor Conference...National Physician Advisor Conference NPAC2019 Bridging the Gap between Clinical Documentation and Safety Scores: Expanding the role of the

• Assembling the team• “PA CDI”

• 1 trauma surgeon

• 4 hospitalists

• Scheduling and communications

• Started May 2017

Creating a New Physician Advisor

Page 21: National Physician Advisor Conference...National Physician Advisor Conference NPAC2019 Bridging the Gap between Clinical Documentation and Safety Scores: Expanding the role of the

PA CDI Distribution of Work

Page 22: National Physician Advisor Conference...National Physician Advisor Conference NPAC2019 Bridging the Gap between Clinical Documentation and Safety Scores: Expanding the role of the

• Case Examples• PSI 11 Post op respiratory failure

• PSI 09 Post op hemorrhage

• PSI 12 Peri op PE/DVT

• PSI 06 Iatrogenic Pneumothorax

Physician Advisor PSI Reviews

46

14

26

CONFIRMED PSI CONFIRMED PSI, BUT DISAGREE NOT A PSI

PSI Reviews, FY 18

Page 23: National Physician Advisor Conference...National Physician Advisor Conference NPAC2019 Bridging the Gap between Clinical Documentation and Safety Scores: Expanding the role of the

CDI queries

Page 24: National Physician Advisor Conference...National Physician Advisor Conference NPAC2019 Bridging the Gap between Clinical Documentation and Safety Scores: Expanding the role of the

PA CDI- Medical Staff Affairs Reviews

106

38

90

35

ACCEPTABLE NOT ACCEPTABLE ACCEPTABLE NOT ACCEPTABLE

HISTORY & PHYSICAL POST OP NOTES

Note Reviews, FY 18

Page 25: National Physician Advisor Conference...National Physician Advisor Conference NPAC2019 Bridging the Gap between Clinical Documentation and Safety Scores: Expanding the role of the

• Common Diagnoses Queried• Respiratory Failure

• Sepsis

• ATN

• Encephalopathy

PA CDI- Clinical Validation (DRG Denials)

51

76

Proceed with Appeal Agree with Denial, do not Appeal

Clinical Validation Reviews, FY 18

Page 26: National Physician Advisor Conference...National Physician Advisor Conference NPAC2019 Bridging the Gap between Clinical Documentation and Safety Scores: Expanding the role of the

• How much do PSIs cost?

• PSI Reduction and Leapfrog/CMS Star Rating Improvement

• Value to the medical staff office and HIM

• DRG Appeals have true value

PA CDI ROI

Page 27: National Physician Advisor Conference...National Physician Advisor Conference NPAC2019 Bridging the Gap between Clinical Documentation and Safety Scores: Expanding the role of the

PA CDI ROI

26 18 35

$117,004

$-

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

$140,000

OVERTURNED PENDING UPHELD

CDI DRG Appeal ReviewsMay 2017- Dec 2018

Page 28: National Physician Advisor Conference...National Physician Advisor Conference NPAC2019 Bridging the Gap between Clinical Documentation and Safety Scores: Expanding the role of the

PA CDI ROI

Page 29: National Physician Advisor Conference...National Physician Advisor Conference NPAC2019 Bridging the Gap between Clinical Documentation and Safety Scores: Expanding the role of the

www.acpadvisors.org

[email protected]

Thank you!

Contact Info


National Physician Advisor Conference · National Physician Advisor Conference NPAC2019. The Physician Advisor As Revenue Integrity Bridge March 13, 2019 - Atlanta, Georgia ... May

National Physician Advisor Conference · National Physician Advisor Conference NPAC2019. The Physician Advisor As Revenue Integrity Bridge March 13, 2019 - Atlanta, Georgia ... May

A Primer on Physician Health Care Fraud · A Primer on Physician Health Care Fraud Health Care Compliance Association Physician Practice Compliance Conference October 5, 2007 Philadelphia,

A Primer on Physician Health Care Fraud · A Primer on Physician Health Care Fraud Health Care Compliance Association Physician Practice Compliance Conference October 5, 2007 Philadelphia,

The Advisor - MD Preferred Physician Services · By Kevin Kroskey, CFP®, MBA Preparing for the New (Tax) Normal By Tanina Frouge Linden, CFP® Physician Opportunities . Financial

The Advisor - MD Preferred Physician Services · By Kevin Kroskey, CFP®, MBA Preparing for the New (Tax) Normal By Tanina Frouge Linden, CFP® Physician Opportunities . Financial

Compliance in Physician Employment and Hospital- …hcca-info.org/Portals/0/PDFs/Resources/Conference...Compliance in Physician Employment and Hospital-Physician Integration Winn W.

Compliance in Physician Employment and Hospital- …hcca-info.org/Portals/0/PDFs/Resources/Conference...Compliance in Physician Employment and Hospital-Physician Integration Winn W.

National Physician Advisor Conference of acute organ dysfunction Occasionally, the third-party contractors will mention SOFA scores, but without any specific citing of the SOFA criteria

National Physician Advisor Conference of acute organ dysfunction Occasionally, the third-party contractors will mention SOFA scores, but without any specific citing of the SOFA criteria

Top 8 physician advisor resume samples

Top 8 physician advisor resume samples

Acute Quality Standards Dan Beckett Acute Physician CMO Advisor for Acute & General Medicine.

Acute Quality Standards Dan Beckett Acute Physician CMO Advisor for Acute & General Medicine.

DECA Updates Summer Conference 2012 Karen Sneary, State Advisor.

DECA Updates Summer Conference 2012 Karen Sneary, State Advisor.

Health IT Summit Washington D.C. 2014- Case Study Dr. Ed Chung, Physician Advisor

Health IT Summit Washington D.C. 2014- Case Study Dr. Ed Chung, Physician Advisor

Yes we can! US Uni Advisor Training Conference

Yes we can! US Uni Advisor Training Conference

Physician Advisor & UR Team Boot Camp San Antonio, TX · CHAIR Day Egusquiza, President, AR Systems, Inc. FACULTY R. Phillip Baker, MD, Physician Advisor, Self Regional Healthcare

Physician Advisor & UR Team Boot Camp San Antonio, TX · CHAIR Day Egusquiza, President, AR Systems, Inc. FACULTY R. Phillip Baker, MD, Physician Advisor, Self Regional Healthcare

Slockett and bogue natl physician well being conference april 5 2013

Slockett and bogue natl physician well being conference april 5 2013

Venturing Advisors Guide · Explain the elements of an advisor conference Describe three elements of an effective advisor conference Explain how an advisor BOR is a tool for personal

Venturing Advisors Guide · Explain the elements of an advisor conference Describe three elements of an effective advisor conference Explain how an advisor BOR is a tool for personal

THE ROLE OF THE PHYSICIAN ADVISOR. "The role of Medical Director or Physician Advisor for Case Management often requires the review of other physicians’

THE ROLE OF THE PHYSICIAN ADVISOR. "The role of Medical Director or Physician Advisor for Case Management often requires the review of other physicians’

National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

National Physician Advisor Conference · Lesson #7, Second Example: What was it like in the 1960s when the Medicare program began? Sheehy and Courtney, J Hosp Med, 2017; Lowenstein,

2013 AIM Hospital Marketing Conference How to Build Physician Leaders AIM Annual Conference April 13, 2013 1:00 – 1:45 p.m. BUILDING PHYSICIAN LEADERSHIP:

2013 AIM Hospital Marketing Conference How to Build Physician Leaders AIM Annual Conference April 13, 2013 1:00 – 1:45 p.m. BUILDING PHYSICIAN LEADERSHIP:

National Physician Advisor Conference · 2019-03-04 · •Medical record review, for the purpose of determining medical necessity, requires a licensed medical professional to use

National Physician Advisor Conference · 2019-03-04 · •Medical record review, for the purpose of determining medical necessity, requires a licensed medical professional to use

HCCA Physician Compliance Conference

HCCA Physician Compliance Conference

Documentation Impact and the Physician Advisor

Documentation Impact and the Physician Advisor

March 2016 Expertise in the Role of Physician Advisor or ...indusmente.com/wp-content/uploads/2016/03/Article... · Physician Advisors and Medical Directors are a crucial part of

March 2016 Expertise in the Role of Physician Advisor or ...indusmente.com/wp-content/uploads/2016/03/Article... · Physician Advisors and Medical Directors are a crucial part of