ACPA Update December 2021

In this Update Editor's Note Insist on Covered or Not Covered Putting the Physician into Physician Advisor Using CDI  Collaborative Conversations! President's Corner ‌ ‌ ‌

Editor's Note Ronald Hirsch, MD, FACP, CHCQM-PHYADV, CHRI Member, ACPA Advisory Board  Editor, ACPA Update

A new variant? It’s labeled Nu. Please, no. (edit- the official name for the new variant is Omicron but the pun was too good to delete.) As I write this, Michigan and Minnesota are dealing with surges, and the data on the new Merck oral antiviral appears good but not as good as originally thought. The airports are once again jammed, and anti-vaccine sentiment remains high. South Park is supposed to be parody but their Thanksgiving episode jumps forward about 40 years when the pandemic is finally ending.   As you know, January 1st brings with it not only hangovers but also the latest iterations to the inpatient only list. As I am sure you are aware, CMS reversed course and is no longer eliminating the list, and they put back on the list most of the surgeries they removed on January 1, 2021. What is not going back on the list? All of the total joint procedures remain off the list, from shoulder down to ankle. But remember, if the surgery is a revision, it has a different CPT code and is inpatient only. Some of the spine surgeries remain not inpatient only but they have a myriad of permutations so always check the code. CMS also reversed course with Ambulatory Surgery Centers (ASCs) and is no longer permitting almost 200 surgeries they added in 2021. But, ASCs can still do total hips and knees and all the cardiac caths, stents, pacemakers, and ICDs they want. But remember, the patient’s out-of-pocket cost for a procedure that pays over $7,800 at an ASC may exceed the obligation at a hospital so while the ASC may sound appealing, if they don’t have a Medicare supplement, they will be paying more.  In this issue we get an article from the Case Management Society of America (CMSA) on the collaboration between ACPA and CMSA, a report from Dr. Ben Kartchner about physician advisors and CDI, and a provocative article from Dr. Bernie Emkes on “experimental” care and insurance coverage. If you have not weighed-in on the November Observation Committee cases, there is still time. Just go to https://www.surveymonkey.com/r/X96RW22 and tell the committee what you would do.       Finally, want to be famous? Write an article for the newsletter. Email me at signaturedoc@gmail.com for the submission guidelines.

Insist on Covered or Not Covered  Bernie Emkes, MD     Member, ACPA Government Affairs Committee

My only real credentials are the MD after my name. I often say – I am just a doctor, but…  In 2003, after many years in private practice and a couple of years leading a local hospital services line and Physician Hospital Organization (PHO), I was asked to assume the role and title of Medical Director Managed Care Services by my national employer. While this was a local job in my home state, it offered many insights into the land of contracting, value-based care, physician behaviors, payer behaviors, and health system behaviors. It opened my eyes to some pretty questionable language and behaviors that fall somewhere between the evidence-based practice of medicine, legal contracts, and actual real-time day-to-day care of patients.   I sometimes said I had one foot in Administration, and the other foot in the Doctor’s Lounge.  There are far too many learnings to cover in one article so today I have chosen to deal with some very specific language often found in payer contracts with hospitals that should never be allowed into such contracts – or at least, bucketed differently than most contracts are today.  The language is – We do not cover Experimental and Investigational (E&I) care (or devices). This is usually followed by a statement that says something like – Because you (the hospital) should have known this was E&I, you cannot bill our member for these services.   These contracts often define “covered” and “non-covered” services, but somehow E&I gets included somewhere else in contract language. My contention is that contracts should ONLY contain the “covered” and “non-covered” statuses, and E&I (if even allowed in the contract) should be just one of the “non-covered” topics.  Why is this important? Almost all contracts allow billing patients if something is “non-covered.” There can be many reasons a service is non-covered. The patient may not be covered on the date of service when provided, benefits for a specific service may not be in place, employers may not have purchased coverage for a certain condition (a good example is bariatric surgery), benefits may have been exhausted in some low coverage plans, or the service may be considered E&I by the payer. If structured as a subset of “non-covered,” then hospitals could still bill for these services and the patient and health plan would need to discuss those implications. The hospital should not be denied payment, be forced to appeal, etc., as the original decision to perform the service, implant the device, or just move forward was between the physician and the patient. As it is, many plans attempt to get free care by simply denying care as E&I leaving the hospital with no recourse.   Why does this change make sense? Let’s discuss the process for plan approval of a new service, drug, or device. It all starts with the Food and Drug Administration (FDA), which evaluates the device or service for safety and efficacy. Once FDA approved, the service is eligible for payment for patients in Traditional Medicare. In certain circumstances, CMS will start the process to develop an NCD. But short of that, payment will be made if the service was determined to be “reasonable and necessary.” However, most private/commercial insurance plans have their own review processes using technology assessment committees, technology assessment councils, etc. This is the process they use internally prior to approving or implementing coverage for these items, even though they are FDA approved. This process takes some period of time. My experience tells me it is often 12 – 18 months.   And that is really the issue!   These services or devices are NOT E&I, as they have FDA regulatory approval. The E&I designation is purely a made-up health plan designation because the plan has not yet run this service, drug, or device through their own technology review process. Experimental and Investigational, in my opinion, only applies PRIOR TO FDA approval. Phase 3 trials might be experimental/investigational and paid for differently (plans often cover the part of the bill unrelated to any E&I device, etc.) Once approved, E&I might be non-covered but hospitals should be paid for the care and device or be able to shift the cost to the patient.   That is why these services need to be defined as a subset under “non-covered.” They then become billable to the member who has already agreed to the service. All hospital registration forms (of which I am aware) include language that states something like – As the patient I am ultimately responsible for any services not covered by my insurance. Making contracts clearer – something is either covered, or non-covered, also simplifies and aligns this registration statement with contract language, and everyone is clear from the start of all the implications.  Dr. Emkes is founder of Emkes Consulting

Putting the Physician into Physician Advisor Using CDI  Ben Kartchner, MD, CHCQM-PHYADV     Member, ACPA CDI Committee

October was a great month to be a physician advisor! I had the opportunity to attend multiple conferences including the National Physician Advisor Conference (NPAC) and came away with new information and motivation to improve my organization and healthcare in general. Topics ranged from regulatory updates, denials management, clinical documentation integrity and its multi-faceted downstream effect, care management, length of stay, leadership, and many others. If you missed my brief overview of agile implementation project management at NPAC, I encourage you to go back and listen. At the very least, you’ll learn how to build a hockey rink in your backyard.  A large number of the presentations at each conference covered topics with financial implications such as denials prevention, appeals, length of stay, and MCC/CC capture. This is not surprising as I’m sure we have all been asked or maybe even asked ourselves the question about “return on investment.” Some of you have likely been responsible for justifying the existence of a physician advisor program. Is the juice of paying a physician to NOT see patients worth the squeeze? If you have been doing this a while, that question is likely viewed as rhetorical. If you are new to the American College of Physician Advisors (ACPA), don’t worry, the answer is a resounding, YES! However, with all this talk about finances and return on investment, it may be easy to get caught up and define a physician advisor as someone who only helps bottom line. I believe nothing could and should be further from the truth.  A presentation given at a conference I attended the end of last month outlined a process for developing a complex care transition team. The presenters noted some discouraging but well-known statistics: the top 5% of the general population account for half of all healthcare costs and the top 1% account for almost a quarter. These high-risk patients have a higher rate of post-acute care needs, require more care management resources, have markedly higher re-admission rates, ED utilization rates, and overall have poorer outcomes. The presenters outlined a strategy for creating a scoring system to identify these high-risk patients and then have them followed for 90 days by a complex care transitions team (CCTT). At 90 days, the patients could either “graduate” from the program or continue to be followed by the CCTT. Their data supported the program with a reduction in re-admissions, ED, and inpatient utilization and average LOS. Certainly, this could be translated into financial benefit (it was) but I think the real success should focus on those patients that benefited. In a shameless plug for NPAC 2022, our hospitalist group, care management, and physician advisors recently were awarded our system’s “President’s Award” for standing up a similar transitions of care team at our hospital in Spokane and we hope to be able to tell you about it in April.  Some of you may be asking: “that all sounds great but, what’s the point? I thought you were part of the Clinical Documentation Integrity (CDI) Committee.” I am, and we’ve arrived. The financial and clinical aspects of being a physician advisor appear to be two sides to the same coin. I don’t really like that analogy because a coin can usually only have one side up at a time and it implies that as a physician advisor I wear two different hats depending on to whom I speaking. It also implies that these two aspects are disparate and siloed and I openly detest silos. However, I do like the analogy of that same coin spinning so that no side ever faces down. I propose that CDI is what makes that happen. How do we justify medical necessity and avoid denials? Documentation. Based on what do we appeal denials? Documentation. How are MCC/CC determined in a chart? Documentation. What determines CMS diagnosis-specific quality measures? Documentation. How do we identify the high-risk patients discussed above? Documentation. You get the point. Although non-physician documentation does play a role, it is minor in comparison to how much is dependent on physician documentation. If implemented correctly, I can think of no individual who has more ability to influence this than the PHYSICIAN advisor.  Change management and how to influence physician behavior or gain “buy-in” is a deep topic and readers probably expected an article and not a book so I can save my thoughts on that for another time. Briefly, I will say that the vast majority of physicians want to do the right thing but just don’t understand what that is. Who better to advise them than one of their peers? If you are not currently working with your CDI department, I would recommend you start there. Work to break down silos between CDI, utilization management, and quality. Move away from the old method of CDI for MCC/CC capture and sole financial benefit. Provide education on which ICD-10 codes are part of CMS’ hospital readmission reduction program to your care management team. The list goes on. If you are not well versed, check out the CDI section of the ACPA website. For new physician advisors, we will be working on some CDI 101 materials that we hope to be ready at the end of Q1 2022. Stay tuned and keep reading!  Dr. Kartchner is a Medical Director and Physician Advisor for Multicare in Spokane, WA

Collaborative Conversations! Melanie A. Prince, MSS, MSN, BSN, NE-BC, CCM, FAAN

The Case Management Society of America (CMSA) is excited about the collaborative partnership with the American College of Physician Advisors (ACPA). ACPA’s vision is complementary to the core ideology of CMSA and the practice of case management. ACPA’s vision is to provide the necessary resources to enable the physician advisor to assume a leadership role in assisting organizations to successfully navigate the healthcare system now and in the future, (ACPA online source, https://www.acpadvisors.org). Case managers advocate for patients, clients, families, and family support systems as they navigate the healthcare system while coping with the challenges of complex illnesses, conditions or injuries. Case managers collaborate with multidisciplinary teams of professionals such as physician advisors, therapists, specialty practice professionals, ancillary personnel, and behavioral health staff. The goals are the same…to facilitate a clinical experience that results in safe, effective, quality outcomes across the healthcare spectrum in a sometimes complicated health delivery system. Interprofessional leadership collaboration is important to advance organizational goals to drive real impact on policies and procedures that change peoples’ lives.  CMSA believes in collaborative partnerships and multi-organizational projects that shape the future of health care. When organizations deliver a united voice on policies and clinical procedures, institutions of care benefit from a coordinated approach that ultimately achieves standardization, safety, and reliability. The critical piece, however, is to ground policies and procedures in evidenced-based practice. Both of our organizations advocate for evidenced-based practice and are committed to improving the healthcare system for all stakeholders. ACPA and CMSA help patients/clients navigate the healthcare system and CMSA is posturing to be at the forefront of change in our emerging healthcare industry. CMSA will create a multidisciplinary forum for healthcare education and innovation at their 2022 Annual Conference, June 1 – 4, 2022 in Orlando, Florida. The theme is: Forging a Path to the Future of Case Management. A plethora of speakers, organizations, sponsors and clinicians will converge at the Gaylord Palms, Orlando for four days of planning, learning and yes, collaborations. Be a part of the collaborative conversations and join them for this important and impactful gathering of healthcare professionals. For more information, visit www.cmsa.org.   Melanie Prince is president of CMSA.

American College of Physician Advisors President's Corner

December 2021

We are in the final stretch of my first year as president of the American College of Physician Advisors and I’m happy to report my proclivity for cussing has not destroyed the organization! (Apologies to anyone I have not met in person or who has not witnessed one of my presentations who might not get that joke.) But seriously, as a group, we have accomplished so very much this year and I am very proud.  Our efforts to make the ACPA more like a community – more personal, inclusive, and interactive, started with the addition of a new position within our Board of Directors, the Vice President of Member Engagement. In this role, Dr. Clarissa Barnes has surpassed every hope and expectation I held back in January. If you are on LinkedIn, Facebook, Twitter, or Instagram, you can find ACPA there with news, updates, announcements, or simply a message to make you smile. Our members consist of many thought leaders across the nation and we hope to bring more of them directly to you through social media in 2022, so stay tuned. And, if you are not yet signed-up for at least one of the free platforms listed above, please join us!  In a time when everyone’s plate feels full absolutely all of the time, Drs. Ronald Hirsch and Alvin Gore have been successful in fielding, collecting, and collating valuable information and advice from the field as editor of this newsletter, ACPA Update, and Physician Advisor Survey Champion. The survey results have just been released and it's our biggest collection of data yet, filled with insights about the profession and those practicing within it (yes, including compensation). Take advantage of these member-only benefits! You’ll find articles in our newsletter with information you won’t find anywhere else, with the exception of our conference. And, these articles are from all of you! We don’t have a curated staff submitting pieces for the newsletter on a scheduled basis. We’re highlighting YOU and YOUR WORK so please continue to submit those articles to Dr. Hirsch at signaturedoc@gmail.com. We want to help you shine!  While 2019 was the first time we highlighted pediatric physician advisors at the National Physician Advisor Conference (NPAC) and our Pediatric Committee was launched, committee chair Dr. Denise Goodman and her team truly made 2021 the year the ACPA turned a spotlight onto the subspecialty which is “pediatric physician advisordom.” Most are familiar with the topic of medical necessity denials and appeals, but have you reviewed our Pediatric Denials Library at https://www.acpadvisors.org/content.aspx?page_id=22&club_id=90610&module_id=456061 ? This unique collection of challenging, pediatric-specific denials and examples of successful appeal strategies is not only a stellar resource for you, but also a simple way you can participate and contribute to the collective knowledge base. This library is not a trove of made-up scenarios, but REAL (PHI-redacted) cases. In order to keep it growing, we need your cases and lessons-learned! If you are a physician advisor who works with pediatric populations, please consider participating in your ACPA community in this way, as well.  After a year hiatus due to the onset of the COVID-19 pandemic, I think I can speak for everyone and say we were all thrilled to participate in NPAC this year, even if it was in a virtual format. NPAC 2021 Co-Chairs Drs. Carolyn Dutton and Julie Kolinski fulfilled one of my calls to action from the start of the year – synthesizing not only an incredible panel of speakers, but one which featured multiple individuals who have never been featured in an ACPA event (or, in some cases, ever in a national event), before. 2022 will be no different outside of the glorious news that the conference will be back in person in Austin, Texas! Drs. Emeric Palmer and Elizabeth (Liz) Quinn as NPAC Champion and NPAC 2022 Chair have big plans…and I can’t wait to see all of you next April.  Until then, please continue to utilize and participate in all we have to offer. From the specially-formatted Medicare Inpatient-Only lists past president Dr. Edward Hu will create once again for 2022, to the perpetually growing library of Clinical Documentation Integrity resource sheets for clinicians and physician advisors alike, and our new, interactive, live town halls featuring expert members of our Advisory Board and committees, our focus continues to revolve around your education.    It is my wish that you find moments of delight, solace, laughter, wonder, and stillness within in these last weeks of the year. Thanks to everyone who has worked so hard to make ACPA a stronger organization and everyone who has offered their opinions on new endeavors we’ve shared this last year. You all have made a difference, and we are better for it.

Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADV (Pronouns: She/Her) President, ACPA Dr. Juliet B. Ugarte Hopkins is Physician Advisor for Case Management, Utilization, and Clinical Documentation for ProHealth Care, Inc. in Waukesha, WI.

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