Physician Advisors and RACs: Saving Grace, Defending Dollars

This is a best practice, according to the Medicare regulations, the hospital payment monitoring program workbook, and the screening criteria themselves.

And don't forget to document this second-level review process, because if Medicare sees evidence of a compliant process when they audit, they are far less likely to issue a denial, says Zebrowitz. "[Medicare] knows the likelihood that the denial will be upheld in an appeal is very low."

Zebrowitz believes the keys to an effective program are fourfold. You need:

• A team
• Training
• Content
• A QA process

You need a team of physicians, because physicians have different strengths and competencies. You need someone trained in Medicare rules and regulations, someone experienced in managing appeals, someone trained in utilization management, and someone who understands hospital compliance, to name a few.

A QA process is necessary to ensure your medical decision-making is consistent. And you need to provide your physicians with access to content—"Your silver bullet," says Zebrowitz—including your local standard of care, literature-based, evidence-based consensus standards.

Editor's note: Joe Zebrowitz, MD, executive vice president for Executive Health Resources, will be speaking at the upcoming conference, "Medicare Compliance Forum: A Strategic Approach to RACs, Observation Status and the Role of Physician Advisors," which will be held in Atlanta this October.