Process

Functioning as an off-site Physician Adviser (PA) to hospital clients’ Case/Care Management Departments, St. Clair PA consultants perform second-level admission medical necessity (AMN) case reviews on a "concurrent or Medicare pre-billing" basis with the objective of certifying the proper level of care [LOC- inpatient (IP), observation, or outpatient (OP)] for each patient. Such cases are referred by Case Managers who identify proposed admissions to IP beds not meeting the InterQual or Milliman IP LOC criteria.

In compliance with Medicare LOC regulations, St. Clair PA consultants review and assess concurrently each referred patient’s conditions, signs, symptoms, treatments, and/or test findings through real-time access to the involved medical record via EMR or "email/fax" copied chart documents. They complete the review of such referred AMN cases with a "2-hour turnaround" response, which will be forwarded by email or fax to the Case Managers. In the written AMN referral response to the Case Manager for placement in the patient's medical record, a PA consultant certifies what is the proper LOC with supporting clinical rationale. For any question regarding the certified LOC, a PA consultant is available by cell phone to discuss the case with the Hospital’s Case Manager/Medical Director/PA and, if desired, the responsible hospitalist or attending physician. St. Clair will assign a PA consultant to back up to Hospital Case Manager coverage on weekday evenings, weekends, and/or holidays.

These St. Clair admission reviews will assist a hospital to identify opportunities to admit patients, at an IP LOC with a $5-7,000 MS-DRG payment, who would have otherwise been assigned to an observation or outpatient LOC. Also, such reviews will assist a hospital to avoid admitting, at an IP LOC, some patients who do not meet that LOC medical necessity with resulting potential for a RAC payment denial if audited.