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.