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Updated on: August 19, 2014

Physicians and Payers: Alignment Seen As Possible

By Jon Elion, MD, FACC
Original story posted on: August 18, 2014

Many people feel that physicians and payers are at opposite ends of the spectrum when it comes to reimbursement. I confess that I felt that way for many years, but of late, I have noticed greater and greater alignment of interests and goals. There is certainly is a great overlap when it comes to clinical documentation improvement (CDI).

Payers want accurate and complete data, and bills that match what is documented on the chart. Providers want to be fairly compensated for the resources they expended in caring for the patient, whether that is from a prospective payment plan like Medicare, or per diem reimbursement (as is still used by many payers). The common thread that runs through all this is clinical documentation. If the severity of illness, conditions, and co-morbidities are not fully documented, providers and payers are going to be butting heads.

Last year, United Healthcare terminated its Medicare Advantage contracts with thousands of U.S. physicians. While they never stated the reason outright, it’s a good bet that a payor would look askance at any physician whose resource utilization doesn’t match up with the patient’s severity of illness. One potential cause of such a mismatch is inadequate documentation of just how sick the patient was.

Let me give you one example to illustrate. Consider a scenario in which a patient undergoes a laparoscopic cholecystectomy for cholecystitis. After surgery, the patient develops a fever, high white blood cell count, tachycardia, low blood pressure, rapid respirations, and a painful, tender abdomen. The surgeon orders a CT of the abdomen, consults an infectious disease specialist, and starts an expensive intravenous antibiotic. The patient improves and goes home six days after surgery.

If the surgeon's note is only as specific as the details given above, the best that could be coded would be for the acute cholecystitis and a laparoscopic cholecystectomy. A typical reimbursement would be $8,168, and the expected length of stay would be 2.4 days. The use of a post-operative CT scan, infectious disease consultation, and expensive antibiotics would likely be deemed inappropriate (or at least extravagant) by the payor. If the note had mentioned probable acute peritonitis and probable sepsis, the typical reimbursement would be $17,477, with an expected length of stay of 6.2 days, and the resource utilization would have been appropriate. 

So, whether it’s a quality initiative, patient safety indicators, or resource utilization, you've got to have the chart coded completely and accurately. And the cornerstone is physician documentation.

About the Author

Jon Elion, MD, is a practicing board-certified cardiologist in Providence, R.I. and an associate professor of medicine at Brown University. He has served on the finance committee and board of trustees of one of the Brown-affiliated hospitals, and is well-versed in hospital finances. His experience provides him with the unique combination of in-depth medical and technology knowledge with a proven track record of entrepreneurship and business development.

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