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Physician Advisor Program Metrics

Elizabeth Lamkin, MHA, ACHE, ACPA  | Published on 7/2/2017

Physician Advisor Program Metrics


Elizabeth Lamkin, MHA, ACHE, ACPA

June 2017

The success of Physician Advisor (PA) programs in quality improvement, margin protection and regulatory risk reduction has led to the identification of measureable metrics to evaluate and monitor a PA program. This article will provide an overview and examples of how to measure success and how to use metrics to sustain improvements.

 

Overview

Hospital margins are shrinking and the regulatory environment has intensified leaving hospitals struggling to maintain positive bottom lines and meet regulatory requirements.  To survive, hospitals are working to improve rapidly systems to reduce risk of denials and improve billing compliance.

 

The role of a PA is well recognized as a clinical resource to improve margins and compliance. Successful hospitals also focus on the role of the PA in the revenue cycle to ensure revenue integrity. Figure 1. The PA role can integrate activities across hospital functions, thus linking finance to clinical staff. Resources in Care Management and Physician Advisors shift the focus from back end rework to front end revenue integrity to prevent errors. The front-end engagement with physicians and clinical staff provides concurrent oversight of compliance and reduces denials from medical necessity and documentation errors.

Figure 1. Revenue Integrity Wheel


Indicators and Scorecards

The first step to establishing a successful PA program is a solid job description.[1]  There are many varieties of Physician Advisor from part time second level medical necessity reviews to corporate Chief Physician Advisor roles. Once the role is defined and agreed upon, key performance indicators (KPIs) are required to measure effectiveness.

 

The PA KPIs often overlap with Case Management and finance. Therefore, in conjunction with a PA scorecard, each facility should have an overall utilization scorecard that is reported to the Utilization Management Committee. Reporting mechanisms help ensure accountability and meaningful discussion about and analysis of performance.

 

Performance indicators for a PA program can be broken down into two categories with the necessary sister scorecard from utilization management forming the third critical leg of the stool:

 

1.) Process indicators

2.) Outcome indicators

3.) Utilization scorecard

Examples for each category are presented below.  These indicators are not all inclusive, but meant to provide guidance in development of an organization’s specific indicators.

 

Process Indicators

Process indicators provide feedback and structure to the PA job. They allow comparisons and development of best practices, and provide the opportunity for efficiency improvements.

 

Physician Advisor Monthly Process Indicators

Physician

Indicator

Source of Data

Target

 

Average time from CM first level review to PA completed second level review.

 

 

 

Average time from referral to PA to completion of second level review

 

 

 

Number of second level reviews

 

 

 

Number of physician to physician discussions on bed status

 

 

 

Number of conversions from OBS to IP

 

 

 

Number of peer to peer meetings for appeals

 

 

 

Number of peer to peer meetings for authorization

 

 


 

Physician Advisor Monthly Process Indicators (cont’d)

Physician

Indicator

Source of Data

Target

 

Number of RAC appeal letters written/reviewed

 

 

 

Number of commercial appeal letters written/reviewed

 

 

 

Number of ALJ hearings attended

 

 

 

Number of education sessions taught to physicians

 

 

 

% UMC meeting attendance (Goal: 100%)

 

 

 

% Attendance of other assigned committees (Goal 100%)

 

 

 

 

Outcome indicators

Outcome indicators are as critical as process indicators, which tell when a particular PA is performing efficiently, while another is not.  However, the outcome indicators will demonstrate whether each PA is both effective and efficient, as both are necessary for a successful PA.

 

Physician Advisor Quarterly Outcome Indicators

Physician

Indicator

Source of Data

Target

 

Observation patient - average LOS in hours

 

 

 

Inpatient LOS

 

 

 

Number of OBS to IP conversion

 

 

 

Number of IP to OBS conversions

 

 

 

Number of Code 44s

 

 

 

Number of bill holds for lack of documentation (DNFB)

 

 

 

Number of self-denials

 

 

 

CMI

 

 

 

Readmissions

 

 

 

Authorization obtained for appropriate bed status after peer to peer

 

 

 

Overturned RAC denials on appeal

 

 

Physician Advisor Quarterly Outcome Indicators (cont’d)

Physician

Indicator

Source of Data

Target

 

Number of CDI queries (tracked and trended for reduction based on physician education)

 

 

 

Total number (not dollars) of initial denials

 

 

 

Number of final denials

 

 

 

Dollars in final denials

 

 

 

Total number of overturned denials

 

 

 

Number of denials overturned after peer to peer

 

 

 

Number of successful appeals to ALJ

 

 

 

Cost per case (IP)

 

 

 

Cost per case (OBS)

 

 

 

Utilization Score Card

The Utilization Management Scorecard measures the broader work of Utilization Management function in each facility.

 

Utilization Management Committee Scorecard

Indicator

Source of Data

Target

Length of Stay (ALOS)

 

 

All Payors

 

 

1 Medicare

 

 

2 Medicaid

 

 

3 Commercial

 

 

4 Medicare Advantage Plans

 

 

5 Hospice

 

 

6 Self Pay

 

 

Medicine

 

 

Surgery

 

 


 

Utilization Management Committee Scorecard (cont’d)

Indicator

Source of Data

Target

Outliers (ALOS)

 

 

6-10 days, Cases

 

 

6-10 days, ALOS

 

 

11-15 days, Cases

 

 

11-15 days, ALOS

 

 

16-30 days, Cases

 

 

16-30 days, ALOS

 

 

31-100 days, Cases

 

 

31-100 days, ALOS

 

 

CMI

 

 

All Payors

 

 

1 Medicare

 

 

2 Medicaid

 

 

3 Commercial

 

 

4 Medicare Advantage Plans

 

 

5 Hospice

 

 

6 Self Pay

 

 

Medicine

 

 

Surgery

 

 

Length of Stay Case Mix Adj

Calculated

 

All Payors

 

 

1 Medicare (CMI Adj)

 

 

2 Medicaid (CMI Adj)

 

 

3 Commercial (CMI Adj)

 

 

4 Medicare Advantage Plans

 

 

5 Hospice (CMI Adj)

 

 

6 Self Pay (CMI Adj)

 

 

Medicine (CMI Adj)

 

 

Surgery (CMI Adj)

 

 

Medicare GMLOS

 

 

All Payors

 

 

1 Medicare

 

 

2 Medicaid

 

 

3 Commercial

 

 

4 Medicare Advantage Plans

 

 

5 Hospice

 

 

6 Self Pay

 

 


 

Utilization Management Committee Scorecard (cont’d)

Indicator

Source of Data

Target

LOS/GMLOS

Calculated

 

All Payors

 

 

1 Medicare

 

 

2 Medicaid

 

 

3 Commercial

 

 

4 Medicare Advantage Plans

 

 

5 Hospice

 

 

6 Self Pay

 

 

Uncompensated Days

CM

 

Potential Excess Days (ALOS vs GMLOS)

 

 

Potential Excess Days % of Total Pt Days

 

 

OP in a bed days

 

 

Number of OPs in a bed

 

 

One Day Stays

 

 

Total IP Admissions

 

 

Total IP Discharges

 

 

Total Patient Days

 

 

Number of Cases (1DS) excluding Deliveries

 

 

Percent of Discharges

 

 

Two and Three Day Stays

 

 

Inpatient Discharges LOS 2 or 3 Days

 

 

% of Discharges

 

 

Observation Status

 

 

Observation Total Days (Calculate Equivalent Days)

 

 

Observation OP Days

 

 

Observation LOS in Hours

 

 

Observation OP Cases

 

 

Observation Cases Converted to IP

 

 

Observation IP conversion %

 

 

Observation Patients Discharged Home %

 

 

Observation Days % of Total Patient Days

 

 

Observation OP Cases % of Admissions

 

 

Cost Per Observation Patient

 

 

Net Revenue Per Observation Patient

 

 

Average Admission Time

 

 

Average Discharge Time

 

 

 

 

Conclusion

Physician Advisors are no longer a luxury but a necessity. With the right structure, process and people in place, the metrics and key performance indicators will demonstrate just how valuable PAs are to an organization.  With measurement of metrics and key performance indicators, organizations will be able to create the most tailored and effective PA program possible.

Look for part two in July 2017 when we share a tool for PA program return on investment.