Speakers & Bios

Beyond Denials: Seeing the Bigger Picture with Medicare Advantage Organizations

Focusing on denial prevention can blind providers to more complex tactics payers employ to reduce payments to providers. This session provides a greater understanding of the Medicare Advantage payers for-profit business model and why your hospital’s revenue integrity strategy must evolve at the same velocity as payers’ payment mitigation strategies.

LEARNING OBJECTIVES:

• Attendees will walk away with a greater understanding of the Medicare Advantage payer business model
• Attendees will learn the tactics employed to achieve optimal profit for the payer
• Attendees will also have an opportunity to consider the implications of a number of key Medicare Advantage payer acquisitions that will require pro-active mitigation with new strategies.

 

Dr. Jerilyn Morrissey

Chief Medical Officer, CorroHealth

Dr. Jerilyn Morrissey is a national subject matter expert on CMS regulatory guidance and is passionate about using data and technology to help hospitals navigate complex Medicare regulations as well as understand payer practices and their impact on the hospital revenue cycle. Dr. Morrissey’s experience as a practicing physician, a Physician Advisor for a nationally recognized health system, and as a Director of Clinical Information for a national payer, afford her a unique perspective to solve utilization management’s evolving challenges. Dr. Morrissey received a Bachelor of Arts in Biology from the Illinois Wesleyan University and her medical degree from the University of Illinois. Dr. Morrissey is currently a licensed physician in California.

Making Medical Decision-Making Work for Us

Focusing on denial prevention can blind providers to more complex tactics payers employ to reduce payments to providers. This session provides a greater understanding of the Medicare Advantage payers for-profit business model and why your hospital’s revenue integrity strategy must evolve at the same velocity as payers’ payment mitigation strategies.

LEARNING OBJECTIVES:

• Understand the changes in the Evaluation and Management (E&M) code sets
• Connect E&M documentation with medical necessity and CDI documentation
• Document medical decision making or time-based billing commensurate with level of E&M service billed

 

Dr. Erica Remer

President, Erica Remer, MD, Inc.

A practicing emergency physician for 25 years and physician advisor of a large multi-hospital system turned independent consultant, Dr. Erica Remer is a national expert on documentation, CDI, and ICD-10. Co-host of Talk Ten Tuesdays, Remer is the Chair of the American College of Physician Advisors’ CDI Committee and on the Board of Directors of ACPA. She is on the Editorial Board of ICD10Monitor, cohost of Talk Ten Tuesdays, and a past member of the ACDIS Advisory Board. Her goal is to put MENTATION back into documentation.

Medicare Hospital Payment for Short Stay Inpatient vs. Outpatient Hospitalization

LEARNING OBJECTIVES:

• The concept of “visit status” for hospitalizations is a product of Medicare’s establishment in the 1960’s with a Part A & B
• Differences in hospital payment for hospitalizations with similar services can differ substantially depending on whether they are billed under Part A (MS-DRG payment) vs Part B (C-APC payment)
• Hospital reimbursement for most hospitalizations can be estimated using the CMS IPPS Pricer, CMS Appendix A & CMS Appendix B

 

Dr. Charles Locke

Associate Professor, Johns Hopkins Medicine

Dr. Charles Locke is currently serving as the Chief Operating Officer of the BCCFH COVID Task Force, a joint operation between the State of Maryland Department of Health, Johns Hopkins Medicine and the University of Maryland Medical System. Previously, he served as a Physician Advisor from 2011 to 2013 and the Senior Physician Advisor 2013 to 2021 for the Department of Utilization Review and Clinical Resource Management, Johns Hopkins Hospital. He is also an Associate Professor in the Department of Medicine, Johns Hopkins School of Medicine. He has been active in areas CMS hospital payment and audit policy, including visit status determination, the 2-midnight rule and the Recovery Audit (RA) program. Dr. Locke served a 2-year term as president of ACPA from 2019 - 2020.

Dr. Andrew Hughes

Assistant Professor, Johns Hopkins Hospital

Dr. Hughes is as Assistant Professor in the Division of Pulmonary Critical care at Johns Hopkins Hospital. He is currently the Senior Physician Advisor for the Department of Care Coordination and Clinical Resource Management, Johns Hopkins Hospital and Bayview Medical Center.

Systems Based Practice Elective

In this presentation, physician advisors provide effective solution to address System-based practice education gaps for resident physicians. The study results provide robust evidence indicating substantially improved knowledge as well as awareness of the interprofessional teamwork related to documentation efficiencies, and the interconnectedness of such tasks encountered in real hospitalist jobs.

LEARNING OBJECTIVES:

• Understand innovative strategies to engage physician advisors as educators in a systems-based practice learning experience for resident physicians.
• Apply lessons learned from an educational innovation in systems-based practice to their own institutional settings and practices.

 

Dr. Ahmed Abuabdou

Interim Chief Clinical Officer, University of Arkansas for Medical Sciences

Ahmed Abuabdou, MBBS, MBA, is the Interim Chief Clinical Officer for University of Arkansas for Medical Sciences Medical Center and leads its Physician Advisory program. He holds an academic rank of Associate Professor of Medicine in the Division of Hospital Medicine at the UAMS College of Medicine. Among the several institutional committees he chairs, he chairs the UAMS CDI Committee tasked with developing strategies to improve documentation practices and ensure its integrity. Ahmed is an active member of the American College of Physician Advisors (ACPA) serving the organization as Vice-President of operations and a member of the Clinical Documentation Integrity Committee since its inception in 2016. He authored several educational materials for ACPA including Atrial Fibrillation, Acute Blood Loss Anemia, Post-Procedural Respiratory Failure (PSI-11), and Perioperative Hemorrhage and Hematoma (PSI-9). He achieved CCDS certification from ACDIS in 2018.

Bridging Two Worlds: Applying Quality Improvement Methodology to Physician Advisor Objectives

Physician advisors are institutional leaders in utilization management, denials review, operations, and coding and documentation as well as clinicians. That dual skillset makes us well positioned to lead high impact quality improvement projects that can improve performance on key quality metrics and optimize high value care.

LEARNING OBJECTIVES:

• Explore how to integrate quality improvement methodology with physician advisor objectives
• Examine techniques to identify opportunities and engage your institution/stakeholders
• Review approaches to tracking the impact of your quality improvement projects on physician advisor objectives

 

Dr. Sang Hee Kim

Assistant Professor/Physician Advisor, Ann & Robert H. Lurie Children's Hospital of Chicago

SangHee Kim, MD is a pediatric hospitalist at Ann and Robert H. Lurie Children’s Hospital of Chicago and an Assistant Professor of Pediatrics at Northwestern University Feinberg School of Medicine. As a Physician Advisor, she has engaged in utilization management, operational efficiency, and denials management. She leads projects related to operations and discharge efficiency as well as worked with her colleagues on projects related to improvement of documentation. Her academic interests include quality improvement, development of clinical care guidelines, and medical education.

Dr. Denise Goodman

Attending Physician Division of Critical Care Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago

Denise M. Goodman, MD, MS is a board-certified pediatric intensivist and Senior Physician Advisor at the Ann & Robert H. Lurie Children’s Hospital of Chicago and Professor at Northwestern University Feinberg School of Medicine. She enjoys the organizational and physician engagement as PA, her clinical practice which includes medical directorship of a home tracheostomy/invasive ventilation program, and service as Associate Editor at the Journal of Pediatrics.

Dr. Kiran Kulkarni

Physician Advisor CM, CDI Physician Advisor, Attending Physician, Ann & Robert H. Lurie Children's Hospital of Chicago

Kiran Kulkarni, MD, MS is a Pediatric Hospital Medicine Attending at Ann & Robert H. Lurie Children's Hospital of Chicago and an Assistant Professor of Pediatrics at Northwestern University Feinberg School of Medicine. Her clinical practice includes general pediatric inpatient care, neonatal resuscitation and newborn consultation, as well as pediatric consultation at Shirley Ryan AbilityLab. In addition to her clinical roles, Kiran serves as a Physician Advisor and Clinical Documentation Champion for Lurie Children’s. Her interests include quality improvement, complex care and medical and provider education.

Dr. Nawal Momani

Ann & Robert H. Lurie Children's Hospital of Chicago

Nawal Momani is a Pediatric Hospital Medicine Attending at Ann & Robert H. Lurie Children's Hospital of Chicago and an Instructor of Pediatrics at Northwestern University Feinberg School of Medicine. Her clinical practice includes general pediatric inpatient care, sedation services and immediate care. In addition to her clinical roles, Nawal serves as a Physician Advisor.

Dr. Victoria Rodriguez

Ann & Robert H. Lurie Children's Hospital of Chicago

Victoria Rodriguez, MD, is a fellowship trained pediatric hospitalist and Assistant Professor at Ann and Robert H. Lurie Children's Hospital and the Northwestern University School of Medicine. She brings expertise in medical education and adult learning theory to her role as a Physician Advisor, and has completed the Harvard University Macy Institute Program for Educators in Health Professions. She participates in research, operational, and quality improvement projects in the areas of readmission reduction, discharge optimization, and clinical documentation improvement. She has also lead faculty level continuing education and maintenance of certification (MOC Part IV) projects on utilization management and clinical documentation improvement.

Physician Advisors Role in Preventing Readmissions in Complex Patient Populations

LEARNING OBJECTIVES:

• Explain how physician advisors are uniquely positioned in medical organizations to identify patients with high hospital utilization and help develop strategies for individualized readmission reduction.
• Identify 5 psychosocial factors that contribute to high inpatient utilization and repeated hospital readmissions.
• Summarize how a physician advisor is uniquely positioned in medical organizations to implement and monitor transition of care programs.

 

Dr. Kathryn Kasicky

Kathryn R Kasicky, MD is in her 10th year of practice in internal medicine with focus in hospital medicine and perioperative medicine. She attended medical school at Penn State College of Medicine followed by Internal Medicine residency at Wake Forest Baptist Health where she continued on as a hospitalist. She joined WVU Medicine in 2015 as section chief of Hospital Medicine and transitioned into department of Orthopaedics in 2018 to develop and direct the Orthopaedic Medical Optimization Program. At WVU Medicine - Ruby Memorial Hospital she has been actively involved in the Complex Care Plan Team development. She joined Physician Advisory services for the WVU Health System in January 2022. Dr. Kasicky is board certified by the American Board of Internal Medicine.

Dr. Karen Clark

Karen E Clark, MD MACP, FRCP, CHCQM-PHYADV is a Professor of Internal Medicine in the Section of General Internal Medicine at the West Virginia University School of Medicine in Morgantown, WV. Dr. Clark serves as Medical Director of Utilization Management and Physician Advisory Services at WVU Health System. Dr. Clark earned a BA in Chemistry from West Virginia University and a Doctorate of Medicine degree from the Joan C Edwards School of Medicine at Marshall University. She completed an internship in OB/GYN and a residency in Internal Medicine, both at WVU. Dr. Clark is board certified by the American Board of Internal Medicine and the American Board of Quality Assurance and Utilization Review Physicians. Since completing her training she has practiced in an academic setting in General Internal Medicine and the West Virginia University Student Health Service and has been involved in teaching, clinical research and patient care.

Transitioning Observation to Admission Care, Managing Length of Stay Hours, Discharge Decisions

This session reviews proven solutions optimizing the intersection of clinical decision-making, regulatory requirements, documentation of care, and information technology in electronic health records by providing the Physician Advisor with tools to successfully manage their Observation Services while providing methodology capturing key components for coding and billing complimentary to all stakeholders.

LEARNING OBJECTIVES:

• Describe the use of Place in Observation orders to initiate Observation LOS clocks then advance patient care towards Admission or Discharge.
• Identify reporting tools and data objectives to daily monitor Observation LOS, documentation supporting transition from Observation to Admission, Admission to Observation (CC-44), and Discharge

 

Dr. Robert Leviton

NYC Health Hospitals, Metropolitan Hospital

As Physician Advisor and lnformatician, working collaboratively with hospital clinicians and administrators, utilizing governance structures that drive adoption and change, my focus is developing efficient clinical information technology solutions that align the revenue to care paradigm, while meeting regulatory and compliance standards leads to significant cultural changes impacting documentation integrity, denials, authorizations, enhancing revenue management. As a result, health information technology becomes the bridge between the C Suite and Clinical staff providing outcome and solutions.

Physician Advising in Pediatrics, Medically Necessary for CMOs

Join a CMO/Physician Advisor duo that has successful navigated the development of a robust pediatric PA program nestled within a large multi-system hospital network, learning opportunities for program advocacy and growth.

LEARNING OBJECTIVES:

• Describe CMO/Physician Advisor collaboration from a pediatric care perspective
• Present opportunities where CMOs can advocate for the Physician Advisor to be included as a resource, subject matter expert, and liaison across hospital settings
• Describe how a C-suite executives advocate for Physician Advisors

 

Dr. Alyssa Riley

Physician Advisor/Pediatric Nephrologist, Dell Children's Medical Center

Dr. Alyssa Riley is a pediatric nephrologist and physician advisor at Dell Children's Medical Center, in Austin, TX. A Physician Advisor since 2017 with roots in CDI education, she has been part of an ever-growing team that expanded into utilization review and case management. When not passionately trying to win peer-to-peers, preach efficient documentation, or prevent nephrotoxic kidney injury, you'll probably find Alyssa caddying on a golf course or freezing in an ice hockey rink with her husband and two sons.

Dr. Meena Iyer

Chief Medical Officer and Vice Chair of Clinical Affairs, Dell Children's Medical Center and UT Austin Dell Medical School

Dr. Meena Iyer is a pediatric hospitalist & CMO for Dell Children's Medical Center, Austin, TX. During her tenure, the hospital has expanded to include word class cardiothoracic, comprehensive neurology & neurosurgery, and interventional maternal fetal medicine services.

The Physician Advisor's Role in Supporting Medical Necessity for Post-Acute Care

Beneficiary access to services with Medicare Advantage remains an issue in hospitals throughout the country. Many denials are for post-acute services that would otherwise be covered with original Medicare. With their knowledge and understanding of medical necessity, physician advisors are well poised to assist their care management teams in fighting back. We will discuss Medicare regulatory criteria specific to post-acute care facilities and how physician advisors can lead the way in process development for appropriate next level of care determinations, expedited prior authorization and appealing adverse determinations.

LEARNING OBJECTIVES:

• Understand basic medical necessity requirements for post-acute care services: skilled nursing facilities, inpatient rehabilitation facilities and long-term acute care hospitals
• Understand various appeal processes including patient appeal, appeals on behalf of patient, standard and expedited appeals and QIC escalation
• Discuss and understand how physician advisors can play an integral part in denial prevention, the appeal process and care management support

 

Dr. Benjamin Kartchner

Associate Regional Medical Director of Care Management, Multicare Health System

Dr. Benjamin Kartchner is a board-certified Family Medicine physician in addition to holding certifications of CHCQM-PHYADV from American Board of Quality Assurance and Utilization Physicians and CMPC from the Association of Physician Leaders in Care Management. He began work as a Physician Advisor over 5 years ago and currently supports care management as an Associate Medical Director for Multicare in addition to practicing part time as a hospitalist in Spokane, WA. He has experience serving as a consultant for technology company AIDA and working as a part-time Physician Advisor for Brundage Group. He is the TLC Champion and Chair for Essentials & Fundamentals in addition to serving as a member of the Board of Directors for American College of Physician Advisors.

The Importance of Visit Class Concordance: Optimizing Surgical Compliance and Revenue Capture

This session will review opportunities to measure processes, improve compliance, and optimize revenue capture for planned surgical hospitalizations. Who knew visit class, IPO procedures, and ELOS could be so scintillating?

LEARNING OBJECTIVES:

• Understand types of discordance between visit class, length of stay, and type of procedure code for planned surgical hospitalizations.
• Learn compliance and revenue opportunities related to improving visit class concordance with length of stay and procedural code.
• Consider interventions to broadly improve efficiency and accuracy of visit class.

 

Dr. Emily Boss

Medical Director, Revenue Cycle Performance Improvement; Physician Advisor, Johns Hopkins Medicine

Emily F. Boss, MD, MPH, FACS (nee Rudnick) is a Professor of Otolaryngology, Pediatrics, and Health Policy & Management at the Johns Hopkins University Schools of Medicine and Bloomberg School of Public Health. She is the Medical Director for Revenue Cycle Performance Improvement for Johns Hopkins Medicine and a Physician Advisor for Care Coordination and Clinical Resource Management at Johns Hopkins Hospital. Dr. Boss is a clinician scientist with research focused on patient and family-centered care, health disparities, and surgical outcomes and utilization. She has authored or co-authored more than 100 articles and chapters with funding by the U.S. National Institute of Health. An established surgeon, physician executive, and researcher, she is passionate about performance improvement in healthcare delivery. Dr. Boss believes there is untapped potential to improve health outcomes through enhanced doctor-patient communication and organizational change, especially for the most vulnerable populations.

Self Pay Neonate in the ICU: This is No Joke!

This session highlights the problem of insurance coverage for the youngest ICU patients- the NICU baby. We present a process improvement project at the Cleveland Clinic focused on reducing 'self pay baby'.

LEARNING OBJECTIVES:

• Learn the process and the factors affecting newborns added to insurance policyLearn the process and the factors affecting newborns added to insurance policy
• Learn about multidisciplinary process improvement project to solve systemic issues
• Recognize the role that physician advisors can play in affecting change within complex health systems

 

Dr. Sumana Narasimhan

Enterprise Physician Advisor, Cleveland Clinic

Dr Narasimhan is one of 9 Enterprise Physician Advisors at Cleveland Clinic. She has worked in this role since 2020. She is also a member of the Pediatric subcommittee of the ACPA and is a pediatric endocrinologist in clinical practice.

Management of Behavioral Health Patients: Increase Value of Care and Prevent Denials

"Care of the patient with behavioral health issues and obtaining reimbursement for psychiatric care is challenging in several unique ways including:

• Unique payor structures, many with per diem plans
• Frequent long lengths of stay
• Limited disposition options
• Limited number of physician advisors with psychiatric training or comfort with behavioral health reviews
• Limited inpatient psychiatric beds and outpatient psychiatric resources
• ED crowding with psychiatric boarders
• Documentation challenges

This session will focus on the approach physician advisors and care managers can take to tackle the aforementioned unique aspects of the behavioral health utilization review process to best pro-actively prevent denials and increase value of care."

 

LEARNING OBJECTIVES:

• Identify unique challenges of “pure” behavioral health cases needing acute psychiatric care
• Outline key elements an advisor should include in their behavioral health reviews/ data that should be sent to payors
• Understand differences in P2Ps/appeal process for psychiatric necessity denials

 

Dr. Erin Boyd

Associate Chief Medical Officer, Sound Physicians

Erin Boyd, MD, CHCQM-PHYADV, is Associate Chief Medical Officer for Sound Advisory Services. She began her training in psychiatry after which she shifted her attention to full time internal medicine hospitalist work all while maintaining a strong interest in patients with psychiatric illness in both her clinical and advisory work. She is actively engaged in concurrent and retrospective behavioral health reviews, peer-to-peer reviews, and appeals, mentors physician advisors with non-psychiatric backgrounds in how to most effectively perform behavioral health reviews, and assists hospitals in identifying unique aspects of behavioral health utilization and denials. Prior to her advisory work, she served as hospitalist medical director of a large hospitalist group, has led the hospital utilization committee, and has worked collaboratively with several independent review organizations to help facilitate appeal of payor denials for numerous hospital systems.

Innovation & Observation: Improved Outcomes, Decreased Readmissions, Increased Capacity/Throughput, Financial Viability

This session will discuss observation medicine’s importance to a hospital’s bottom line, to emergency department throughput and patient care with better patient outcomes. Observation medicine results in decreased length of stay, decreased costs, improved ED turn-around- time, improved patient quality of life and satisfaction, decreased hospital admissions and readmissions.

LEARNING OBJECTIVES:

• To understand how the use of observation including geriatric observation can be used to improve patient outcomes, decrease hospitalizations, length of stay and costs; and the tools including protocols, order sets etc. for accomplishing this.
• To be aware of programs such as individualized care plans, multidisciplinary disease specific teams (e.g. sickle cell, CHF), geriatric nurse clinician, observation unit (OU), geriatric OU, expanded home health care, paramedicine, doctor home visits, increased technology, that improve patient care
• To be familiar with the trends in healthcare

 

Dr. Sharon Mace

Professor of Medicine, Cleveland Clinic

Commonly Denied Pediatric Peer to Peers: How We Get to Yes!

"Ugh, not another failed peer to peer! Do peer to peers give you anxiety and challenge your inner peace? In this talk we will run through the foundations of a successful peer to peer by utilizing clinical case examples, role play of various peer to peer scenarios and a review of the supporting literature for our clinical determinations. We will cover the medically complex pediatric patient and common general pediatric specific appeals and denials that we see often at CHOP. By the end of this talk we anticipate everyone will add to their peer-to-peer tool kit!"

LEARNING OBJECTIVES:

• Explain level of care and status assignments for hospitalized patients
• Demonstrate how to successfully complete a Peer to Peer review.
• Leveraging medical literature for successful peer to peers

 

Dr. Lucinda Lo

Physician Advisor CDI & CM, Children's Hospital of Philadelphia

Lucinda Lo, MD, is a practicing pediatric hospitalist at the Children’s Hospital of Philadelphia which she joined in 2003. She is a Clinical Associate Professor of Pediatrics at the University of Pennsylvania School of Medicine and she is board certified with the American Board of Pediatrics. She is currently the physician advisor for CDI and CM. She provides both education to medical staff on topics related to CDI and feedback about their clinical documentation. She fully participates in utilization management and denial reviews as well as formulation of associated institutional policy and practice.

Dr. Sara Hasan

Children's Hospital of Philadelphia

Sara Hasan, MD is Pediatric Hospitalist at the Children’s Hospital of Philadelphia since 2016. She is a Clinical Assistant Professor of Pediatrics at University of Pennsylvania School of Medicine and she is board certified in General Pediatrics. She joined the department of case management in 2020 as physician advisor. In her role as a physician advisor, she draws a lot on the care for children with medical complexity and focuses on planning for safe transitions out of the hospital to home. She actively participates as a medical reviewer for denials and appeals along with being one of the primary physicians responsible for peer to peers for the entire hospital. She is a physician lead in QI initiatives to expedite transitions from the emergency department to inpatient as well as discharge home. She also serves as the medical director for the surgical co-management team.

Outlier Hospitalizations: A Medical Necessity and Capacity Conundrum

LEARNING OBJECTIVES:

• Understand the impact of outlier hospitalizations on hospital capacity
• Assess their own institution's barriers to outlier patient discharge and create solutions directed towards this unique patient population

 

Dr. Andrew Hughes

Assistant Professor, Johns Hopkins Hospital

Dr. Hughes is as Assistant Professor in the Division of Pulmonary Critical care at Johns Hopkins Hospital. He is currently the Senior Physician Advisor for the Department of Care Coordination and Clinical Resource Management, Johns Hopkins Hospital and Bayview Medical Center.

Dr. Charles Locke

Associate Professor, Johns Hopkins Hospital

Dr. Charles Locke is currently serving as the Chief Operating Officer of the BCCFH COVID Task Force, a joint operation between the State of Maryland Department of Health, Johns Hopkins Medicine and the University of Maryland Medical System. Previously, he served as a Physician Advisor from 2011 to 2013 and the Senior Physician Advisor 2013 to 2021 for the Department of Utilization Review and Clinical Resource Management, Johns Hopkins Hospital. He is also an Associate Professor in the Department of Medicine, Johns Hopkins School of Medicine. He has been active in areas CMS hospital payment and audit policy, including visit status determination, the 2-midnight rule and the Recovery Audit (RA) program. Dr. Locke served a 2-year term as president of ACPA from 2019 - 2020.

Fight Like A Lawyer, Part 2: Appeal Letters

Last year Fight Like a Lawyer Part 1 discussed how what I learned in law school helps me appeal payer denials with peer to peers: When the facts are on your side, pound on the facts. When the law is on your side, pound on the law. When neither the facts nor the law are on your side, pound on the table! This year, it's Part 2: You've lost the peer to peer, now what?

LEARNING OBJECTIVES:

• Learn what the Office of Inspector General's report tells us about why we should appeal payer denials.
• Understand why certain words should not be used in appeal letters.
• Be able to determine the best argument for your appeal letter.

 

Dr. Barbara Abrams

Physician Advisor, Orlando Health

Dr. Barbara Abrams is a Physician Advisor with Orlando Health covering both adult and pediatric patients since 2018. She is a graduate of Boston University School of Medicine (1986) and Florida State University College of Law (2005) and completed her Pediatric internship and residency at Cleveland Metropolitan General Hospital. Dr. Abrams has over 20 years of clinical practice (inpatient and outpatient) and has completed a fellowship in Regulatory Medicine at Food and Drug Administration (FDA). She has practiced Disability Law and also worked in areas such as Guardianship and Child Advocacy.

Engaging Learners in Physician Advisor Activities

This session will describe some activities used to engage trainees in Physician Advisor Activities and provide resources to bring back to teach residents and medical students.

LEARNING OBJECTIVES:

• Discuss the varying approaches to education of learners
• Utilize tools to improve education in your institution
• Gather data to improve buy in from education leadership on importance of this topic

 

Dr. Katharine Clouser

Physician Advisor, Hackensack University Medical Center

Katharine Clouser is a hospital pediatrician and Physician Advisor at the Joseph M Sanzari Children's Hospital at Hackensack University Medical Center. She joined as a physician advisor in 2016 and has bene working on pediatric advocacy since that time. She serves as the Vice Chair of clinical affairs and teaches residents and students about topics related to Physician Advisor work.

Dr. Jennifer Goodrich

Physician Advisor, Dell Children's Medical Center

Dr. Jennifer Goodrich is a Pediatric Hospitalist and Physician Advisor at Dell Children's Medical Center, in Austin, TX. She received her MD from the University of Texas Southwestern Medical School in Dallas, TX, and completed a Pediatrics residency at Vanderbilt University in Nashville, TN. She moved to Austin in 2014 to join the faculty at Dell Children's in Austin, where she is currently an Assistant Professor at UT Dell Medical School. She joined the hospital's CDI team in 2020 and enjoys teaching efficient and effective documentation to medical staff. She was excited to develop a section of “Documentation Tips” in an educational guide for a Pediatric Hospital Medicine curriculum published by the AAP in 2022.

Implementation of Utilization Management Reviews in the Emergency Department

This session will discuss key steps to initiate a Utilization Management review process in the Emergency Department. Attendees will learn about staffing model and workflow development necessary for a successful implementation. Resources will be shared for development of documentation and data analysis tools as well.

LEARNING OBJECTIVES:

• Recognize the importance of Utilization Management reviews in the Emergency Department
• Identify strategies to overcome barriers for a successful implementation
• Develop staffing model for emergency department based on anticipated admissions

 

Dr. Anuja Mohla

Medical Director, Revenue Integrity, Christiana Care

Anuja Mohla, DO, MBA, CHCQM-PHYADV is the Medical Director of Revenue Integrity and hospitalist at ChristianaCare in Newark, Delaware. She most recently served as a Senior Physician Advisor and Medical Director of Patient Access and Flow for several years at ChristianaCare before transitioning to her current role. She is dual board certified in Internal Medicine as well as Health Care Quality Management with a sub-specialty designation as a Physician Advisor. A graduate of the Philadelphia College of Osteopathic Medicine, Dr. Mohla went on to complete her Internal Medicine residency at UMDNJ, New Jersey Medical School. She most recently also finished her MBA from University of Massachusetts. She serves on the board of American College of Physician Advisors as the Chair of ACPA Observation Committee. She is a frequent speaker at the national level on the topics of Denial Management, Appeals, and Regulatory requirements.

Ms. Kristin Ann McKee

Manager of Utilization Management, Christiana Care

Kristin McKee is the manager of Utilization Management Department at ChristianaCare. In her current role, she has successfully implemented several new initiatives within Utilization Management department with a significant impact on operational workflow. She graduated from the University of Delaware with a Bachelor of Science in Nursing. She has over 16 years of experience as a bedside nurse with several years of management experience. In her spare time, she loves to travel with her family.

Moving Beyond Medical Necessity. Developing a Clinical-Legal Partnership to Manage Complex Denials

LEARNING OBJECTIVES:

• Attendees will be able to describe unique requirements and benefits for exercising appeal rights under ERISA plans, Medicare Advantage Plans and Commercially issued insurance plans
• Attendees will become knowledgeable about basic common law arguments to support medical necessity appeals including good faith and fair dealing, quantum meriut and promissory estoppel.

 

Ms. Denise Wilson

Senior Vice President, PayerWatch

Denise serves as the Senior Vice President at PayerWatch – AppealMasters. Denise is also President of The Association for Healthcare Denial and Appeal Management. Denise has over thirty years of experience in healthcare, including clinical management, education, compliance, and appeal writing. Denise has extensive experience as a Medical Appeals Expert and has personally managed hundreds of Medicare, Managed Medicare, and Commercial appeal cases and presented hundreds of cases at the Administrative Law Judge level. Denise is a nationally known speaker and dynamic educator on Medicare and Commercial appeals processes, payer behaviors, standards of care, appeal template development, and building a road map to drive the payer to a decision in the provider’s favor. She has educated thousands of healthcare professionals around the country in successfully overturning medical care denials.

Mr. Bill Haynes

Legal Director, Clinical Legal Unit, PayerWatch

Bill Haynes, Esq. serves as the Managing Attorney for PayerWatch, and as the Legal Director of PayerWatch's Clinical-Legal Unit. He is a member in good standing of the Maryland Bar, a member of The Association for Healthcare Denial and Appeal Management, and a member of the American Health Law Association. He has four years of experience in healthcare law, including managed care contract analysis, payer-provider arbitrations, and the independent review processes. Bill helps manage a team of clinicians, attorneys, and paralegals who do research, analysis, and draft language for appeals, independent reviews, and arbitrations, for both government and private payors."

Leadership Lessons from TOPGUN: How to be an Effective Maverick of Change

By unpacking and applying three leadership principles used by the actual TOPGUN staff for the past 50 years, former TOPGUN instructor David Robinson will explain how to bridge silos and foster teamwork to effectively lead change in a complex, dynamic, bureaucratic environment when you don't have formal authority.

LEARNING OBJECTIVES:

• Effectively lead organizational change without formal authority in a complex operating environment
• Apply the philosophical and psychological foundations of leading through influence to generate trust
• Implement best practices for creating a culture of teamwork and organizational performance improvement

 

Mr. David Robinson

CEO, Vertical Performance Enterprises

Senior executive and retired U.S. Marine Corps colonel with over three decades of experience leading complex organizations. Former combat FA-18 pilot and TOPGUN instructor who works with executives at the intersection of strategy, change management, and leadership development to improve organizational effectiveness. Author of The Substance of Leadership: A Practical Framework for Effectively Leading a High-Performing Team. Guest speaker at numerous Fortune 500 training venues and a consultant to companies across a range of industries including finance, logistics, aviation, healthcare, and biotechnology. Featured in Harvard Business Review, Forbes, and Chief Executive Magazine. Former strategy director for the Chairman of the Joint Chiefs of Staff, commanding officer (CEO) of a $12B aviation organization with 250 aircraft and 2,500 people supporting global operations, and recipient of the Bronze Star Medal for supervising over 20,000 combat missions and more than 2,000 medical evacuations while serving as the director of air operations in Iraq.

Dismissals: A New Path to MA Accountability

LEARNING OBJECTIVES:

• Understand Medicare Advantage dismissals, the newest change to the Medicare Advantage reconsideration regulations
• Learn the value of member engagement in Medicare Advantage denials
• Recognize consistent patterns in the Maximus searchable decision database

 

Dr. Edward Hu

System Executive Director, University of North Carolina Health Care System

Edward Hu, MD is an internal medicine physician and physician advisor with UNC Health. He completed his medical education at Washington University School of Medicine, St. Louis, and his residency at Duke University Hospital.

2023 Regulatory Update

An update of the latest regulatory news that every physician advisor needs to know.

LEARNING OBJECTIVES:

• Review the pertinent 2023 regulatory changes
• Examine current audit activity and denial prevention techniques
• Provide update on discharge planning guidelines and roadblocks

 

Dr. Ronald Hirsch

Vice President, R1RCM Inc.

Dr. Ronald Hirsch is a Vice President of the Regulations and Education Group at R1 RCM Inc. Dr. Hirsch was a general internist and HIV specialist and practiced at Signature Medical Associates, a multispecialty practice located in Elgin, IL. He was Medical Director of Case Management at Sherman Hospital in Elgin, IL from 2006 to 2012, where he was Chairman of the Medical Records Committee from 1995 to 2012, and also served on the Medical Executive Committee. Dr. Hirsch is certified in Health Care Quality and Management by the American Board of Quality Assurance and Utilization Review Physicians, certified in Revenue Integrity by the National Association of Healthcare Revenue Integrity, and on the Advisory Board of the American College of Physician Advisors. He is on the editorial board of RACmonitor.com. He is the co-author of The Hospital Guide to Contemporary Utilization Review, with the third edition published in 2021.

Flying Outside the Court of the Payor's Opinion

Many opportunities exist to move denied claims beyond the payer's internal review process. Learn how to increase appeal success by appealing your denials to external (independent) review - outside the court of the payer's opinion.

LEARNING OBJECTIVES:

• After attending this session, participants will be able to describe at least two options for appealing a denial outside of the payer's internal appeal process
• After attending this session, participants will be able to describe the value in advancing appeals through external review
• After attending this session, participants will be able to identify opportunities specific to their situation to take appeals to external review

 

Ms. Denise Wilson

Senior Vice President, PayerWatch

Denise serves as the Senior Vice President at PayerWatch – AppealMasters. Denise is also President of The Association for Healthcare Denial and Appeal Management. Denise has over thirty years of experience in healthcare, including clinical management, education, compliance, and appeal writing. Denise has extensive experience as a Medical Appeals Expert and has personally managed hundreds of Medicare, Managed Medicare, and Commercial appeal cases and presented hundreds of cases at the Administrative Law Judge level. Denise is a nationally known speaker and dynamic educator on Medicare and Commercial appeals processes, payer behaviors, standards of care, appeal template development, and building a road map to drive the payer to a decision in the provider’s favor. She has educated thousands of healthcare professionals around the country in successfully overturning medical care denials.

Evolution of the Physician Advisor as a Leader and Valued Thought Partner

Many opportunities exist to move denied claims beyond the payer's internal review process. Learn how to increase appeal success by appealing your denials to external (independent) review - outside the court of the payer's opinion.

LEARNING OBJECTIVES:

• After attending this session, participants will be able to describe at least two options for appealing a denial outside of the payer's internal appeal process
• After attending this session, participants will be able to describe the value in advancing appeals through external review
• After attending this session, participants will be able to identify opportunities specific to their situation to take appeals to external review

 

Dr. Minnie Bhupathi

Physician Advisor, Brundage Group

Dr. Minnie Bhupathi is a board-certified physician and have been in clinical practice for nearly 2 decades prior to transitioning to healthcare management and administration. She has varied experience in medical staff management, physician engagement and education, clinical documentation integrity, utilization management, quality, and care coordination areas. Dr. Bhupathi has held various positions, most recently as the Associate CMO at a large hospital in the greater Atlanta area, as a hospital-based physician advisor, and medical director for healthcare consulting/advisory companies. She is passionate about the important work that physician advisors perform and the value they provide to frontline clinical staff and health systems in the current complex healthcare milieu.

Dr. Erin Boyd

Associate Chief Medical Officer, Sound Physicians

Erin Boyd, MD, CHCQM-PHYADV, is Associate Chief Medical Officer for Sound Advisory Services. She began her training in psychiatry after which she shifted her attention to full time internal medicine hospitalist work all while maintaining a strong interest in patients with psychiatric illness in both her clinical and advisory work. She is actively engaged in concurrent and retrospective behavioral health reviews, peer-to-peer reviews, and appeals, mentors physician advisors with non-psychiatric backgrounds in how to most effectively perform behavioral health reviews, and assists hospitals in identifying unique aspects of behavioral health utilization and denials. Prior to her advisory work, she served as hospitalist medical director of a large hospitalist group, has led the hospital utilization committee, and has worked collaboratively with several independent review organizations to help facilitate appeal of payor denials for numerous hospital systems.

Dr. Chris Boyle

Chief, Stewrdship and Physician Advisor Services, NorthShore University HealthSystem

Dr. Christopher Boyle serves as Regional Chief of Stewardship and Physician Advisor Services at NorthShore – Edward-Elmhurst Health, a nine hospital health system in Northern Illinois. In this role Dr. Boyle has oversight for the acute care and clinical integrated network (CIN) aligned programs. For acute care he partners with hospital based leaders on shared goals related to stewardship of acute care resources, clinical documentation integrity (CDI), quality improvement and hospital UM. For population health he partners with CIN counterparts for CIN-aligned CDI program for accurate HCC capture, while also collaborating on resource stewardship related to post-acute services. He has direct oversight for delivery of all physician advisor services that support these efforts. Dr. Boyle earned his medical degree from Columbia University College of Physicians and Surgeons and completed his Internal Medicine training at the University of Washington with a specialty focus in HIV Medicine and Primary Care.

Dr. Amber Isley

VP of Enterprise Physician Advisors, Ascension Health

Amber Isley, MD, FAAFP currently serves as the VP of. Ascension Physician Advisor Services which encompasses 140 hospitals across the U.S. She currently works with market physician advisors, revenue cycle, CDI, and finance to manage denial mitigation and LOS effortS. Dr. Isley formerly served as Vice President, Quality & Patient Safety and Regional Physician Advisor, Ascension Florida and Gulf Coast, and Grifols Center Medical Director. As Vice President, she managed hospital quality initiatives, regulatory submissions and process improvement projects for the Ministry Market’s nine acute care hospitals, inpatient rehabilitation facility and various free-standing emergency rooms. She also worked with hospital presidents and chief clinical officers to prioritize quality, safety and performance outcomes. During her tenure, she helped Ascension Florida and Gulf Coast reduce hospital-acquired infections, mortality rates and readmissions across all facilities, participating in root-cause analyses, serious events and peer review mitigation efforts. Dr. Isley earned her medical degree from Morehouse School of Medicine, Atlanta, and completed her residency at Mayo Clinic, Jacksonville, Florida, where she also served as chief resident. She is the mother of 3 adult children.

Dr. Elizabeth Quinn

System Vice President, CommonSpirit

Dr. Elizabeth Quinn currently serves as the System Senior Vice President for CommonSpirit Health’s Internal Physician Advisor Service (IPAS). Upon graduation from the University of California, San Francisco School of Medicine, Dr. Quinn practiced as an Internist and Hospitalist in the Bay Area for over 10 years, co-founding the first Hospitalist program for a 130 acute bed stroke center. She served as President for the California Association of Interns and Residents, and was a delegate to the American Medical Association. Furthermore, she served as a Director for the Oakland Children’s Hospital’s Multicultural Curriculum Program, creating and implementing multicultural education programs for the Alameda County Medical Center and Public Health Department. Ultimately, Dr. Quinn decided to transition from clinical practice to physician advisory. After several years of honing her skills as a physician advisor, she joined the newly formed Internal Physician Advisor Service (IPAS) at Catholic Health Initiatives. Since then, she has helped to develop and establish the system-wide IPAS department of what is now CommonSpirit Health, one of the largest not for profit health systems in the United States. In 2022, Dr. Quinn served as Co-Chair for NPAC 2022, Exploring the Spectrum: Leadership through Collaboration and Diversification. Dr. Quinn is a champion for the expanding roles of physician advisors within healthcare. She recognizes the profound impact physician advisors can have on Compliance, Revenue Cycle, Quality Assurance, Population Health, and many other areas of the healthcare landscape. More importantly, Dr. Quinn is passionate about how the physician advisor can and should remain a strong advocate for all patients.

Juliet Ugarte Hopkins

President, ACPA

Juliet B. Ugarte Hopkins, MD the current President of ACPA. She completed her training at Advocate Lutheran General Children’s Hospital located outside Chicago and then practiced as a pediatric hospitalist for a decade. While there she was also medical director of pediatric hospital medicine and vice chair of pediatrics before transitioning into her current role as her health system’s first physician advisor. Dr. Ugarte Hopkins is a member of the RACMonitor.com editorial board, and she was the first physician board member for the Wisconsin chapter of the American Case Management Association. She has made multiple appearances on the Monitor Mondays and Talk Ten Tuesdays webcasts, is a national speaker for topics related to the physician advisor scope of work, and has been featured on KevinMD.com.

Promoting Clinical Documentation Excellence Amongst Medical Trainees

This session will explore the intersection between your expertise as a physician advisor and opportunities in medical education to promote high quality clinical documentation.

LEARNING OBJECTIVES:

• Define the LCME and ACGME core educational milestones related to clinical documentation.
• Identify opportunities to apply physician advising expertise to develop a curriculum in clinical documentation excellence for medical trainees.
• Describe specific educational strategies for creating a new curriculum in clinical documentation excellence.

 

Dr. Joseph Cristiano

Physician Advisor and Assistant Professor of Internal Medicine, Atrium Health Wake Forest Baptist

Dr. Cristiano is a physician advisor for Atrium Health Wake Forest. He holds certifications as a Certified Clinical Documentation Specialist (CCDS) and the American Board of Quality and Utilization Review Physicians (CHCQM-PHYADV). He created the physician advising program on Clinical Documentation Excellence at his institution. Through collaborative efforts, he helped pioneer the development and implementation of several impactful health system initiatives, including a multi-diagnosis clinical indicators policy, clinical decision support for documentation excellence for health system providers, and a successful initiative to improve provider response to documentation queries.

From Data to Action: Practical Analytics to Drive Change and Innovation

Discover the transformative power of analytics in hospital utilization practices in our comprehensive beginner-to-advanced presentation. Uncover practical use cases through real-life scenarios which will help you become leaders in hospital change. We will cover the need to acquire future-proof skills like analytics for career longevity in today's blistering revolution led by AI. Engage in this interactive session which will incorporate live questions, test your knowledge with a quiz (yes there's a prize). Gain access to valuable downloadable materials which will be available exclusively to presentation attendees. Don't miss this interactive opportunity.

LEARNING OBJECTIVES:

• Be able to analyze metrics and data trends and, in turn, isolate areas of utilization opportunity.
• Design project improvements with the foresight of understanding the impact on metrics and performance to ensure project effectiveness prior to utilization of larger resources or large practice changes.

 

Dr. David Zirh

West Region Lead Physician Advisor, BayCare Health System

David Zirh has a clinical background in Hospitalist Medicine and Sports Medicine. Since joining BayCare as a Physician Advisor, his focus has been on developing hospital metrics. Today, with two data analysts, the group is able to exert significant influence on executive leadership and initiate changes to hospital utilization practices and operations. Dr. Zirh has degrees in Biochemistry and Biophysics from the University of Pennsylvania, an MBA from Temple University, completed residency at the University of Hawaii followed by a fellowship at Atlantic Sports Health. He is currently working towards a master’s in applied analytics from Columbia University. His website HospitalNerd.com aims to provide education and free tools to support hospitals in the field of utilization and analytics.

Ms. Stephanie Slankard

Lead Data Analyst, Utilization Management, BayCare Health System

Stephanie Slankard joined the Clinical Analytics & Utilization team in 2021 to support the go-live of more robust clinical analytic reporting for the Utilization Management Committees across BayCare’s Hospital Division. Through her previous roles in Medical Staff Services and Care Transformation, she gained a basic understanding of medical staff governance, evidence-based best practice guideline development, and project management (Lean certification in-process). Prior to joining BayCare in 2017, Stephanie worked in administrative and patient-facing roles in post-acute services for over five years with experience in Admitting/Registration, Social Services, Marketing and Operations. She is lean certified and graduated with a Master of Health Administration from Virginia Commonwealth University with an emphasis in elder care services.

Disruptive Innovation in Healthcare: Physician Advisors Role with Case Management

LEARNING OBJECTIVES:

• Understand the concept of “disruptive innovation” and how it can be used in healthcare.
• Review how disruptive innovation contributes to meeting the goals of the Triple/Quadruple/Quintuple Aim.
• Describe the process of “disruptive innovation” and identify through case study review how the “disruptive innovation” process impacts patient care.

 

Dr. Colleen Morley

President, Case Management Society of America

Dr. Colleen Morley DNP RN CCM CMAC CMCN ACM-RN FCM is the Associate Chief Clinical Operations Officer, Care Continuum for University of Illinois Health System and the current President of the Case Management Society of America National Board of Directors. She has held positions in acute care as Director of Case Management at several acute care facilities and managed care entities in Illinois, for over 16 years; piloting quality improvement initiatives focused on readmission reduction, care coordination through better communication and population health management. She is the recipient of the CMSA Foundation Practice Improvement Award (2020) and ANA Illinois Practice Improvement Award (2020) . Dr. Morley also received the AAMCN Managed Care Nurse Leader of the Year in 2010 and the CMSA Fellow of Case Management in 2022. Her 1st book, “A Practical Guide to Acute Care Case Management” was released in February, 2022

Getting Some Skin in the Game: A High-Impact CDI Gem (Skin Failure)

LEARNING OBJECTIVES:

• Describe and identify skin failure based on clinical presentation
• Articulate the difference between skin failure versus a pressure injury
• List at least three strategies to document and code skin failure appropriately

 

Dr. Kristen Berlin

Physician Advisor, BayCare Health System

Kristen Berlin Ph.D., MD, CHCQM-PHYADV, MBAc is a Physician Advisor for BayCare Health System. Prior to reinventing herself as a Utilization Management Physician, she practiced medicine as a Pediatric Hospitalist for 20 years at Johns Hopkins All Children’s Hospital and Saint Joseph’s Children’s Hospital in the Tampa Bay area. She currently works with system-based denials management and PA-led real-time observation management. She is the champion for skin failure across her hospital system, providing documentation guidance and education. She is the Pediatric Medical Director for Suncoast Hospice/Empath and the Medical Director for the Southwest Region of the Florida Department of Juvenile Justice. Dr. Berlin is currently pursuing her MBA in Healthcare Administration. When she is not working or studying, she is globetrotting with her teenagers and volunteering with rhinos at the Ol Pejeta Conservancy in Kenya.

Creating a Centralized Appeals/Denials Unit

Variation in denial management can lead to inefficiencies and inconsistencies in getting paid for the work you do. Learn how to create, and some of the benefits of, a centralized appeals and denials unit within a health system.

LEARNING OBJECTIVES:

• Learn one way to create a centralized denial management unit
• Understand the benefits and drawbacks of a centralized unit
• How to identify barriers to creating a centralized unit.

 

Dr. Ryan McKennon

Medical Director of the Clinical Denial Recovery Unit, Henry Ford Health

Medical Director of the Clincal Denial Recovery Unit for Henry Ford Health. Previous Medical Director of Utilization Management for Henry Ford Hospital Adjunct Law Professor at Western Michigan Cooley Law School - teaching Healthcare Compliance.

Leadership and Reporting Structure of Utilization and Physician Advisors

LEARNING OBJECTIVES:

• Utilization as Central to High Value Health Care
• Performance Improvement & the Value Proposition
• Options for Career Growth, Leadership, Reporting Structures & Compensation

 

Dr. Justin Krawitt

Dartmouth Health Med Dir of UM & CDI, Dartmouth Health

Dr. Krawitt is an Assistant Professor at the Geisel School of Medicine at Dartmouth and the Medical Director of Utilization & Clinical Documentation at Dartmouth Health. He is the founder and president of Hanover Physician Advisors. As Medical Director of Utilization and Clinical Documentation and consultancy his responsibilities include operations across the cycle, utilization, clinical documentation, quality, risk, coding, denials, compliance, care management, and physician engagement. Hanover Physician Advisors (HPA) specializes in health systems assessment, training, and support focused on ensuring revenue capture and quality metric improvement. He trained in Internal Medicine at Dartmouth-Hitchcock Medical Center. He obtained his MD at the University of Louisville School of Medicine, his MHCDS at the Tuck School of Business at Dartmouth College, and received his bachelor’s degree from the University of Vermont. He is a practicing Hospitalist, board certified in Internal Medicine and Health Care Quality & Management.

Where's the MEAT? Physician Advisors and a Comprehensive Ambulatory CDI Program

With complete and accurate capture of Hierarchical Condition Categories growing in significance and scrutiny, Physician Advisors are key to improvement and compliance efforts in the ambulatory setting. This session will review a variety of activities for impactful and sustained engagement in HCC-focused ambulatory CDI.

LEARNING OBJECTIVES:

• Describe strategies that physician advisors can employ to educate on the importance of documentation in HCC capture in both primary and specialty care
• Summarize the role of audits in ambulatory CDI as a tool to improve documentation
• Identify key aspects of the partnership between the ambulatory CDI team and Physician Advisors at NorthShore University HealthSystem

 

Dr. Purvi Shah

Medical Director, Population Health - Complexity Capture and Post-acute Care, NorthShore University Health System

Purvi K. Shah, MD is a primary care internist and Medical Director, Population Health - Complexity Capture and Post-acute Care at NorthShore University Health System in Evanston, IL. She studied biology and French at Washington University in St. Louis prior to attending Vanderbilt University School of Medicine as a recipient of the Canby Robinson Scholarship. After completing her internal medicine residency at Northwestern University, she joined the professional staff at NorthShore University Health System in 2009 and has been part of the Physician Advisor program since 2020.

It’s Not the Plane, It’s the Pilot-Harnessing Relationships Transform Peer-to-Peer

Appealing payor denials is a critical process for any healthcare system. While highly valuable, peer-to-peer appeals can be frustrating for the physician advisor given the variability between payors and lack of consistency between encounters. We invite you to come learn how Intermountain Physician Advisor Services transformed the peer-to-peer process by harnessing relationships and standardizing expectations to create a symbiotic process with one of the largest payers in our market.

LEARNING OBJECTIVES:

• Relationships matter and fostering these relationships creates high value in physician advisor work.
• Patient care is complex and benefits from a multidisciplinary approach even at a peer to peer level.
• Automation and scalability of workflow relieves administrative burden, improves accountability, and ensures efficiency as our impact grows.

 

Dr. Beau Bailey

Physician Advisor Services, Intermountain Health

Beau Bailey is an adult and pediatric hospitalist. After spending years in hospitalist leadership, medical group board leadership, and hospital administration, he transitioned to working with Intermountain's physician advisor services (IPAS) in 2019. He is a regional provider educator for IPAS. He is also involved in utilization review at Intermountain's Primary Children's Hospital and leads physician education there. He is the lead physician for appeals and denials for the Intermountain system. He is a general inpatient hospice provider with Inspiration Hospice and is very involved in medical student education as the site director for clinical clerkships for his region for students from Rocky Vista University. In addition to medicine, he is passionate about coaching and spends most of his free time coaching his sons' football, baseball, and basketball teams.

Dr. Kyle Clarke

Physician Advisor Services, Intermountain Health

Dr. Kyle Clarke, MD has worked as a physician advisor for Intermountain Health since 2017. He received his BS in Biology from Brigham Young University in 2007. After graduating from the University of Nevada School of Medicine in 2012, he completed his residency in internal medicine in 2015 at the University of Utah. He was worked as a hospitalist for Intermountain Health since 2015.

Weaving a Physician Advisor “Web” to Becoming an Indispensable Enterprise Asset

“If you know the enemy and know yourself you need not fear the results of a hundred battles.”

LEARNING OBJECTIVES:

• Learning different avenues for self-education vs formal academic degrees.
• Learning how to gain trust so that you may influence policy.

 

Dr. Larry Field

CMS MRAC Contractor Medical Director, Provider Resources Inc.

Larry is a 20-year direct care providing Internist who transitioned into the Physician Advisor role in 2010 and has been a Chief Medical Officer of a 421-bed acute care hjospital, was a Medical Director for the CMS BFCC Patient and Family QIO and is currently the CMS Medical Director for the Medical Review Accuracy Contractor and the Recovery Auditor Validation Contractor. He is one of the founding members of the American College of Physician Advisors and served on its Board of Directors and as part of the executive operations team as Treasurer for 5 years.

Objection, that Question is Leading! Understanding Query Compliance and Industry Best Practices

Love them or hate them, queries are an essential tool used to help ensure clinical documentation accuracy. A noncompliant query jeopardizes the ability to ensure clinical accuracy. Join me for this session where we will review the components of a compliant query and gain an understanding of the appropriate use of the various query formats. You will come away from this session with all of the knowledge needed to ensure that your queries are compliant, and you are up to date on industry best practices.

LEARNING OBJECTIVES:

• Identify all elements of a compliant query
• Identify the appropriate use for each type of query format: open ended, multiple choice, yes/no and verbal queries.
• List all elements needed to ensure industry best practices are followed as per the 2022 Query Practice Brief

 

Dr. Adriane Martin

Vice President of Physician Services, Enjoin

A native of Ft. Worth Texas, Adriane Martin, DO,FACOS, CCDS, graduated from the University ofNorth Texas Health Science Center with herDoctorate of Osteopathy. She completed hergeneral surgery residency at Osteopathic MedicalCenter of Texas/Ft. Worth in 2004. Dr. Martin is aFellow of the American College of OsteopathicSurgeons and her professional affiliations includethe American Medical Association, the AmericanOsteopathic Association and the American Societyof Breast Surgeons. Dr. Martin has been practicinggeneral surgery for 15 years and has been a part ofthe Enjoin team since 2014.As Vice President of Physician Services, Dr. Martindirects many initiatives within the company tosupport operations and ongoing company growth.She leads all internal and external efforts for ourphysician team to support our clients withactionable data and educational content. With herextensive knowledge of documentation and codingprinciples combined with her clinical surgicalexperience, she brings a level of clinical and codingacumen unparalleled in the industry.

Could Scheduled “Peer To Peer” Discussions Decrease Commercial Readmission Denials?

Is your hospital systems experiencing an increase in readmission denials from commercial payers? Might there be a better appeal process than the current written appeal? Might there be a better way to classify a readmission? Come learn about one system’s experience with a local payer willing to make a change in the way they look at readmissions. Maybe there is a better future for readmission denial appeals!

LEARNING OBJECTIVES:

• The learner will understand the current CMS readmission reduction program’s history and purpose.
• The learner will analyze the current readmission reduction process for commercial payers at one academic health system.

 

Dr. Tamara Doehner

Physician Advisor/ Sr. Medical Director of Utilization Management, Nebraska Medicine

Tamara Doehner is a board-certified Internal Medicine physician who transitioned to be the Physician Advisor for Nebraska Medicine in 2018. She has a Masters in Healthcare Administration, is a Fellow of the American College of Physicians and a Fellow of the Society of Hospital Medicine. She has served as the President of the Medical staff at Methodist hospital. She currently practices as a private practice Hospitalist. She spent 15 years as the Medical Director of the Methodist Hospitalist program in Omaha Nebraska. Outside of work she enjoys spending time with family, traveling, cooking and reading historical fiction.

No Business Degree? No Problem. Business Skills for the Physician Advisor

Business skills can create opportunities for career advancement but not everyone has time for grad school. In this session, we’ll cover 3 critical skills that can set you apart: Data collection and analysis, ROI calculation, and building a strong business case.

LEARNING OBJECTIVES:

• Identify 3 critical skills necessary to lead organizational or departmental strategy
• Differentiate and interpret 3 established tiers of data.
• Outline a stepwise approach to achieving robust data collection

 

Dr. Jeny McNair

President, Physician Advisor On Call

Dr. Jeny McNair is a Physician Executive, Physician Advisor, Hospitalist, Wife, Mother, and nomadic creative. She is the President of Physician Advisor on Call, a consulting division of Med-Metrix. Physician Advisor on Call helps facilities mitigate compliance risk and recover revenue as early as possible in the revenue cycle by placing patients in the appropriate level of care. Dr. McNair’s career roles have included frontline Physician Advisorship, National Medical Directorships in UM/UR and Case Management, Clinical Transformation and Population Health Management. Along the way, she collected expertise in process improvement, operations, business development, project management, talent development and leadership. Dr. McNair attended the University of Texas Health Science Center at San Antonio followed by an Internal Medicine residency at Wake Forest University Baptist Medical Center in North Carolina. She currently resides in Texas with teenagers, dogs, cats, and a husband.

Talk to me Goose Strategies Every Wingman Should Deploy When Targeting PSIs

"This presentation reviews key educational concepts related to PSI reporting, the reporting of complications and the risk adjustment methodology that every navigator should understand. Concepts discussed include the Agency for Healthcare Research and Quality (AHRQ) inclusionary and exclusionary criteria, ICD-10-CM guidelines related to reporting complications, present on admission indicator reporting and risk adjustment. If you feel the need, the need to succeed, this information is key and a required component when preparing your providers for their mission of documentation excellence. "

LEARNING OBJECTIVES:

• Identify the four key educational concepts needed to prepare providers to succeed in patient safety indicator dog fights.
• Identify documentation strategies, only a Top Gun wingman could provide in PSI defense.
• Successfully eject from aircraft, when applying PSI exclusionary criteria

 

Ms. Laurie Prescott

Interim Director, ACDIS

Laurie L. Prescott RN, MSN, CCDS, CCDS-O, CDIP, CRC is the interim Director of ACDIS and the CDI education director at HCPro in Middleton, Massachusetts. She is an instructor for the CDI Boot Camps, a subject matter expert for the Association of Clinical Documentation Improvement Specialists (ACDIS), a member of the CCDS-O exam and ACDIS Advisory Boards. She is also the author of The Clinical Documentation Improvement Specialist’s Complete Training Guide and ACDIS Pocket Guide series.

Get to Say “YES”

This presentation reviews key educational concepts related to PSI reporting, the reporting of complications and the risk adjustment methodology that every navigator should understand. Concepts discussed include the Agency for Healthcare Research and Quality (AHRQ) inclusionary and exclusionary criteria, ICD-10-CM guidelines related to reporting complications, present on admission indicator reporting and risk adjustment. If you feel the need, the need to succeed, this information is key and a required component when preparing your providers for their mission of documentation excellence.

LEARNING OBJECTIVES:

• Able to create an effective process to reduce denials
• Learn the strategy to reduce denials.

 

Dr. Alka Farmer

Medical Director, Cooper Hospitalist Program and Physician Advisor Program, Cooper University Hospital

Alka Farmer is currently working as a Medical Director of Cooper Hospitalist Program, Cooper PA program at Inspira Health Network and PA program at Cape Regional Medical Center also an Assistant Professor of Clinical Medicine at CMSRU. She graduated valedictorian from B.J. College of Medicine in India and completed her residency in Internal medicine at Saint-Joseph Medical Center, in NJ in 2008. Afterwards joining the division of Hospital Medicine at Cooper. Dr. Farmer played an instrumental role in redesigning the work flow of PA program which helped them achieve the competitive reduction in denial rate, reducing avoidable delays, improve throughput and integration of CDI. Dr. Farmer also developed UM elective rotation for the IM residents which allows residents to learn the basics of UR and denial management while in training.

Convincing Your Hospital that They Need a Recuperative Care Facility

Medical Respite facilities provide care for people experiencing homelessness who are well enough to leave the hospital but not well enough to be on the street. These facilities provide care in an optimal setting and save many hospital bed days. We will describe our journey in opening such a facility in Porland, Maine and the benefits of doing so.

LEARNING OBJECTIVES:

• Defining Recuperative Care and its role in the healthcare continuum
• Comprehending the benefits of developing a recuperative care facility to the individual, the health system, and the community
• Sharing early data after 6 months of operation

 

Dr. Christopher Wellins

Senior Medical Director of Utilization Management, Maine Medical Center

Dr. Wellins is originally from Newton, MA. He received a BS in Biology from Duke University in 1987. He went on to complete a medical degree at the University of Vermont College of Medicine in 1993. He completed his residency in Internal Medicine at Maine Medical Center in Portland, Maine and during that residency also completed a Masters in the Evaluative Clinical Sciences from Dartmouth College in 1996. After completing residency Dr. Wellins joined an Internal Medicine Practice in Cape Elizabeth, Maine where he also resides. Dr. Wellins started the Physician Advisor Program at Maine Medical Center in 2010 and that program now provides services to the 9 hospital MaineHealth System. In his free time Dr. Wellins enjoys playing squash and doing whatever he can in, around, or on the ocean. He has served as the Chief Medical Officer for Sailing Ships Maine since the summer of 2021.

Dr. Renee Fay-Leblanc

Chief Medical Officer, Greater Portland Health

Dr. Renée Fay-LeBlanc was born and raised in Portland, Maine and completed her bachelor’s degree in biology at the College of the Holy Cross in Massachusetts. Dr. Fay-LeBlanc attended the University of Vermont College of Medicine, where she was inducted into the Alpha Omega Alpha honor society and Phi Beta Kappa. She completed her residency in Internal Medicine at New York University. From 2006 to 2014 she practiced Internal Medicine at Maine Medical Partners in Cape Elizabeth, Maine. Since 2014, Dr. Fay-LeBlanc has served as the Chief Medical Officer at Greater Portland Health. During this time, the organization has grown from two sites to thirteen, serving over 12,000 patients by providing primary care, integrated behavioral health, substance use treatment, infectious disease, psychiatric and dental services. Dr. Fay-LeBlanc serves on the Board of Licensure in Maine and Avesta Housing. She enjoys running and baking and lives in Portland with her family.

UM for the Tik Tok Generation: Scenarios in Pediatrics for the Non-Pediatricians

This session will summarize distinguishing characteristics of Pediatric hospital review, followed by 8 case vignettes, representing common issues at different ages. For each case, a typical presentation supporting Observation will be followed by factors that might support Inpatient level of care.

LEARNING OBJECTIVES:

• Recognize what makes Pediatric Utilization Review different
• Recognize how age may affect the presentation of Pediatric illnesses
• Recognize how Children with Special HealthCare Needs may differ in their need for hospital care

 

Dr. Cheryl Reid

Cheryl S. Reid, MD, FAAP, FACMG is a consultant Physician Advisor doing hospital level of care reviews for Physician Advisor On-Call, a division of Med-Metrix. Dr. Reid received her MD at Rutgers Medical School, followed by Pediatric residency at Montefiore Hospital Medical Center in Bronx, NY and Fellowship in Clinical Genetics at Johns Hopkins Medical Institutions. After board certification in both Pediatrics and Clinical Genetics, she founded a Division of Genetics at what is now Cooper Hospital of Rowan Medical School. After 11 years, Dr. Reid started a genetics private practice for the next 13 year and then took an employed position as a Medical Director at Horizon NJ Health. She was then recruited to a new Aetna Medicaid plan as Medical Director/Acting Chief Medical Officer, moving to the national Medical Review team during plan restructuring. She retired from full time employment in 2022.

Demonstrating the Value of a Physician Advisor Program

Physician engagement in the revenue cycle is critical as operating margins shrink and administrative burdens increase. A strong PA program can connect mid-revenue cycle departments and guide staff through challenging clinical issues. We will review the role of PAs, what to look for when hiring, and examples of their value.

LEARNING OBJECTIVES:

• Articulate the value of a physician advisor program to revenue cycle departments.
• Discuss how physician advisors promote physician engagement with the revenue cycle and quality.
• Examine how a physician advisor program can promote efficiency within middle revenue cycle teams.

 

Dr. Timothy Brundage

CEO, Physician Advisor, Brundage Group

Dr. Timothy Brundage is CEO and physician advisor at Brundage Group. Dr. Brundage founded the company in 2004, and in 2022, Brundage Group made the Tampa Bay Business Journal’s ‘Fast 50’ list of fastest growing private companies. Dr. Brundage travels the country as a physician peer educator and lecturer with a focus on breaking down departmental silos in hospital organizations and unifying clinical documentation across quality, utilization, denials and CDI. He is passionate about increasing the value of the physician advisor role within hospital systems. Dr. Brundage is a frequent presenter at national and chapter conferences for ACDIS, AHIMA, ACMA and ACPA, including Leadership and Physician Advisor Conferences. He is a past board member of ACDIS and past co-chair of the CDI committee for ACPA. Dr. Brundage was selected by Tampa Bay Business Journal as a Health Care Heroes award winner in the health care educator category.

Quiz Bowl

Physician engagement in the revenue cycle is critical as operating margins shrink and administrative burdens increase. A strong PA program can connect mid-revenue cycle departments and guide staff through challenging clinical issues. We will review the role of PAs, what to look for when hiring, and examples of their value.

LEARNING OBJECTIVES:

• Following this session the provider will have a better understanding of observation status being used appropriately
• Following this session the provider will have a better understanding of extended recovery, observation, inpatient and outpatient in a bed statuses and when appropriate to use them

 

Ms. Tiffany Ferguson

CEO, Phoenix Medical Management

Tiffany Ferguson is CEO of Phoenix Medical Management, Inc., the case management company. Tiffany serves is an adjunct professor at Northern Arizona University, Department of Social Work and on the American College of Physician Advisors (ACPA) Observation Subcommittee. Tiffany is a regular contributor to RACmonitor, Case Management Monthly, serves on the editorial board for CMSA Today, and commentator for Finally Friday. She is a weekly correspondent on SDoH for the news podcast, Monitor Monday. After practicing as a hospital social worker, she went on to serve as Director of Case Management and quickly assumed responsibilities in system level leadership roles in Health & Care Management, which includes CM, UR, CDI, HIM, and coding. She has held c-level responsibility for a large employed medical group which included value-based arrangements, PCMH, and outpatient care management. She is a licensed social worker, ACM, and CMAC certified.

Dr. Bartho Caponi

Medical Director, Utilization Management, UW Health

Dr. Caponi has been an internal medicine hospitalist since 2008 and a utilization management physician since 2012. He has been an ACPA member and active on the Observation Committee since 2015 and Vice Chair of the committee since 2021.

Dr. Ahmad Kilani

Medical Director, Cleveland Clinic

Ahmad Kilani, MD, MBA, MLS, MSIT, CHCQM-PHYADV, FACP, is the medical director of Cleveland Clinic Physician Advisers group and regional medical director of Cleveland Clinic Quality Alliance. He is a Fellow of American College of Physicians, a Fellow of American College of Healthcare Executives, and board-certified in Healthcare Quality Management through the American Board of Quality Assurance and Utilization Review Physicians. He is also a member of observation committee at ACPA.

Dr. Anuja Mohla

Anuja Mohla, DO, MBA, CHCQM-PHYADV is the Medical Director of Revenue Integrity and hospitalist at ChristianaCare in Newark, Delaware. She most recently served as a Senior Physician Advisor and Medical Director of Patient Access and Flow for several years at ChristianaCare before transitioning to her current role. She is dual board certified in Internal Medicine as well as Health Care Quality Management with a sub-specialty designation as a Physician Advisor. A graduate of the Philadelphia College of Osteopathic Medicine, Dr. Mohla went on to complete her Internal Medicine residency at UMDNJ, New Jersey Medical School. She most recently also finished her MBA from University of Massachusetts. She serves on the board of American College of Physician Advisors as the Chair of ACPA Observation Committee. She is a frequent speaker at the national level on the topics of Denial Management, Appeals, and Regulatory requirements.

Dr. Bernie Ravitz

Dr. Ravitz completed his Residency in Internal Medicine at Mount Carmel Mercy Hospital in Detroit Michigan. Post Residency Dr. Ravitz pursued a fellowship in Chemical Dependency at the National Institute on Alcohol Abuse and Alcoholism in Bethesda Maryland. Dr. Ravitz is certified with the American Board of Addiction Medicine. Dr. Ravitz formally practiced Emergency Medicine for 17years and was previously Board Certified in Emergency Medicine. Dr. Ravitz also has certifications with The American Board of Quality Assurance and Utilization Review Physicians, with a subspecialty in Physician Advising. A Certified Physician Advisor in Clinical Documentation Improvement and Integrity. Dr. Ravitz has been a Physician Advisor since 2005 (Medstar Health) Dr. Ravitz is the Assistant VPMA for Medstar Good Samaritan Hospital / Medstar Union Memorial Hospital, Baltimore Maryland. A founding member of the American College of Physician Advisors and serves on the Emeritus Board of Directors. Previous Chair for the Observation committee.