The Physician Advisor Handbook

The American College of Physician Advisors is pleased to announce the publication of "The Physician Advisor Handbook", co-authored by Dr. Pooja Nagpal and Dr. Ven Mothkur and edited by Dr. Daniel Zirkman and Dr. Steve Meyerson. This handbook offers a comprehensive review of the multiple areas of influence and levels of expertise that are within the scope of a well-versed physician advisor as a valued member of the hospital's leadership team and is now available for purchase at Amazon Books.

Current ACPA members can read an online version of the book free of charge.

Click Here.

This is a must read for physician advisors at any level of experience and is a useful tool to share with other members of your organization's leadership including care managers, utilization team members, compliance officers, quality and patient safety experts and the entire administrative leadership team.

Online Course


Our Mission

To promote and expand the prominent role of the Physician Advisor in today's rapidly changing healthcare environment through education, certification, mentorship, and collaboration.

Our Vision

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.

   
  

Latest News...

Surveying the MOON

Edward Hu, MD CHCQM-PHYADV , Member of the ACPA Board of Directors

A New MOON

CMS made two important releases in the first week in August that will help hospitals manage the intricacies of the Medicare Outpatient Observation Notice (MOON). We refer the reader to the draft version of the MOON.

First, you will notice that this draft has not been assigned an official OMB number yet. It also contains several differences to the previously proposed MOON released in April. The most obvious change is that there is now a large free text area stating "You are not an inpatient because:" where hospitals are instructed to give the "specific reason" the patient is in outpatient observation. This section will cause hospitals the most consternation, because explaining the "why" will be very difficult without delving into Medicare regulations (which admitting providers often do not understand). Any detailed explanation will likely give rise to more questions than answers. CMS does note that they will consider “checkboxes with common reasons” in the future which suggests that hospitals could develop their own check boxes to use as an explanation.

CMS felt that the NOTICE Act required them to leave in reference to a beneficiary's Part B cost sharing requirements for physician services, even though copayments for doctor services are essentially the same whether an inpatient or outpatient. In the final rule Preamble, CMS acknowledged that in many instances the "observation bundle" (APC 8011) will only trigger a single copayment rather than "a copayment for each hospital service you get," but elected not to include this explanation on the MOON.

The next section attempts to explain eligibility for SNF care after a hospital stay. The statements here will be accurate for most patients, although CMS recognizes that certain alternate payment models have a 3 day SNF waiver that does not require the same qualifying inpatient stay. CMS is choosing to not mention that in this section, leaving it up to the hospital to explain that in the additional information section on the back if applicable. The "NOTE" section contains a huge omission, one that ACPA asked CMS to include but they did not.

                "NOTE: Medicare Part A generally doesn't cover outpatient hospital services, like an observation stay. However, Part A will generally cover medically necessary inpatient services if the hospital admits you as an inpatient based on a doctor's order..."

The omission is that this section omits any reference to the rules that govern an inpatient decision. ACPA suggested that a statement be included that the status decision is made based on Medicare policies without regard to beneficiary cost-sharing or SNF eligibility. Our statement was specifically referenced in the published comments but not responded to. Hospitals should be ready to explain that "your doctor cannot just write an inpatient order so Part A will cover your stay."

CMS removed the reference to calling the Quality Improvement Organization if the patient has a concern about the quality of their care, based on numerous comments (including ACPA's) that beneficiaries may erroneously believe that the MOON and the outpatient observation decision are appealable. They are not appealable. Instead, there is only a generic reference to the 1-800-MEDICARE number.

Page 2 of the form starts with an explanation of non-coverage of self administered drugs (SADs) by Part B. CMS addressed commentary by ACPA and others that the OIG will not penalize a hospital that routinely discounts or waives SADs as long as OIG requirements are met. If a hospital does waive or discount SADs, CMS will allow the hospital to state that in the "Additional Information" section. One of the OIG requirements is that the discount is not marketed or advertised. CMS' guidance should help allay any concerns that stating your SAD policy in the MOON "Additional Information" section would be construed as marketing or advertising...

Read the full article here


Featured Article

Peering into Medicare Advantage Peer-to-Peer:

A 12 Step Program for P2Ping 

Michael A. Salvatore, MD FACP CHCQM 


Payers are becoming increasingly addicted to making denials of payment.  Addictions are grudgingly hard problems to correct. One of the most effective methods has been The 12 Step Program. For now Medicare Advantage denial addiction is a fact of our Physician Advisor lives. We all must take steps to deal with them. 

Here are my 12: 

1.    Don’t show your cards first

In poker it is axiomatic that when you raise a bet and ‘call’, your opponent shows his cards first. When doing P2P always ‘call’ to find out what their argument is for making the denial. Often this will reveal a denial based on an incomplete review of the record, which allows you to point out a deficiency in the denial. This gives you momentum in winning the appeal. If you offer a rationale for overturning the denial first, that allows the peer to uphold his denial without ever telling why the denial was made – you learn nothing. Always ask to see their cards first. 

 

Read the full article here                               Archived Articles