The current climate of health care payment take backs by governmental payers spawned a new industry: firms who support compliance efforts and provide legal services during a RAC audit. Companies like these provide front end consulting services to facility providers and in the event an encounter’s medical necessity is called into question, they will be there to represent the facility during the appeal process.
These firms, comprised of attorney’s, physician’s and other clinical and clerical staff review real time clinical information and offer advice on how to proceed with a patient’s visit. If that visit is scrutinized these firms will represent the provider during the appeal process. Could anyone have imagined health care would evolve to this place? A place where providers would partner with firms such as these to protect themselves? In an era of declining reimbursements, when clinicians are having to do more with much less it is disconcerting that the engaging of these services have become commonplace.
Executive Health Resources (EHR) (http://www.ehrdocs.com/index.php) is one such firm. They boast high success rates in RAC denial appeal and have been solely endorsed by the American Hospital Association. EHR has a unique formula in that it conducts a peer to peer review process. Hospital physicians contact EHR physicians to review cases that, for example, utilization management is questioning the appropriate level of care. Within twenty four hours a response is received by the facility. If in the event of a RAC denial EHR will represent the facility.
EHR is just one example of how clinical expertise is valuable outside the facility or physician practice. At one time medical training was useful in limited settings, providing hands on care to patients for example. Now, insurance companies, law and consulting firms employ individuals with this training as the rules implemented by governmental payers are quite dynamic. It takes a team of clinical and legal advisors well versed in compliance and regulatory guidelines to navigate this ever changing landscape.
One could question if this is really a change for the better. Yes, it has opened more career opportunities for those with a passion for medicine, but not necessarily desiring an involvement in direct patient care. However, if practicing medicine requires a staff of attorney’s and consultants on retainer to merely keep in step with Medicare and its changes can your clinicians focus on your care? Or are they preoccupied with what your insurance will permit them to treat? Worse yet, wondering if three years later those services will be deemed not appropriate and payment revoked. Is healthcare truly the better for this?