Case Management

Effective physician advisors enhance documentation

Case Management Monthly, December 1, 2010

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The rules for making proper level-of-care decisions are lengthy and confusing, which makes the role of the physician advisor within the utilization review (UR) committee extremely critical, says Deborah K. Hale, CCS, president and CEO of Administrative Consultant Service, LLC, in Shawnee, OK.

Good physician advisors put the accuracy of UR processes on their shoulders, so they need to be very credible in their decision-making process and not just a rubber stamp for admission necessity protocols. They do not simply keep their nose to the admission criteria but are brave enough to step up and make a good clinical decision, Hale says.

Hale and Gregory Palega, MD, JD, physician advisor for Med Management in Vestavia Hills, AL, spoke about the physician advisor’s role in assigning level of care during the HCPro audio conference “Observation Services Versus Inpatient Admission: Assign Proper Level of Care and Prevent Denials.” 

The following is one of the case studies Palega presented, which illustrates how an effective physician advisor can work with the attending physician, comb through the medical record, and enhance documentation to prevent reimbursement denials. 

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