Certifications

EdiPhy Advisors: Physician Advisor Services

“Doing the right things right at the right time.”

— from Malcolm Baldrige’s concept of Integrated Enterprise Excellence, the basis for The Malcolm Baldrige National Quality Award

Physician Advisor Overview

Concurrent Medical Necessity

EdiPhy Advisors physician advisor services

uses actively practicing board certified MDs as physician advisors.

These MD physician advisors understand the challenges faced by attending

physicians on a daily basis. Our physician advisors receive support

from a team of experienced RNs who understand the complex criteria-based

 issues and the timing and certification requirements necessary to

receive Medicare, Medicaid, and commercial insurance reimbursement.

Leveraging our expertise and collaborative approach will strengthen

your staff’s knowledge and understanding of CMS regulations and

guidance in practical ways that can support the hospital’s ability

 to obtain correct payment for services rendered. Our physician advisors

 review cases concurrently to support staff in real time, or

retrospectively to support internal compliance goals, including

self-audits.

MD/JDs lead EdiPhy Advisors regulatory compliance and physician

regulatory education efforts, thus bridging the legal and clinical

chasm. EdiPhy Advisors physician advisors are board certified, and our

operating model uses actively practicing physicians who demonstrate

professional excellence and strong communication skills.

EdiPhy Advisors physician advisors are “at your service” around the

clock to assist with patient status decision issues, documentation and

certification requirements and continued stay reviews. EdiPhy Advisors

assists hospitals and other health care providers with the all-important

 determinations of whether patients should be classified and billed as

inpatients or outpatients with or without observation services.

 

Timing is important for medical necessity of patient status decisions

 as the timing of the inpatient order determines whether a case is

subject to the benchmark or presumption for Medicare billing purposes.

The concurrent review process facilitates complete documentation needed

for compliance with health care law and CMS rules, regulations, and

guidance. The concurrent process also enables real-time feedback to

client staff to ensure that documentation or process deficiencies are

addressed.

Our physician advisors are also experienced with conducting

peer-to-peer discussions with both attending physicians and Medical

Directors of health plans, addressing Medicare medical necessity

guidelines and coverage requirements for Skilled Nursing Facilities and

Inpatient Rehabilitation Facilities (IRF), evaluating continued stay

cases.

EdiPhy Advisors believes that actively practicing physicians are best

equipped to know state of the art medical treatment protocols and can

effectively use this knowledge both to document medical necessity and to

 communicate with practicing physicians. As such, our business model

uses actively practicing physicians as physician advisors. The

communication between physicians is enhanced when the physician advisor

has the credibility of active practice.

EdiPhy Advisors’ team of board certified and actively practicing

physicians is committed to providing physician-to-physician advisor

services and to demonstrating professional excellence and strong

communication skills. Our clients view our physician advisors as

important pieces in their compliance and education puzzles. Equipped

from their own experience with first-hand knowledge of communication

barriers in health care provider organizations, EdiPhy Advisors

physician advisors assist clients with strategies to improve

communications in order to enhance dissemination of legal and regulatory

 updates. In this way and through formal medical staff education

(EdiPhycation), we work to provide support for clients’ ongoing

compliance efforts and initiatives.

Whether needed to support internal compliance & quality

initiatives or to respond to a government (or other 3rd party) audit,

EdiPhy Advisors is a valuable resource to clients in reviewing medical

records for patients post-discharge. These retrospective reviews have

the potential to identify billing errors that may be either random or

systemic. Once identified, EdiPhy Advisors staff is experienced in

designing corrective process and/or education to correct any systemic

issues identified.

Self-auditing is an important compliance initiative. Audits ensure

compliance with changing regulations and provide valuable information

relative to the potential need for process improvement and/or

educational efforts. Audits also identify process deficiencies and

weaknesses and provide a basis for ensuring integrity with revenue

requirements. EdiPhy Advisors conducts audits both as part of routine

compliance audits and to address special needs, such as responding to an

 internal complaint, question or issue that has arisen at a health care

facility.

Retrospective Medical Necessity