By Tom Tinsman, MD

AFMC’s accredited review work helps guide providers to meet quality standards of care, and prevents fraud and abuse on behalf of both public and private health plans. Reviewers help ensure that reimbursed services are provided in the most efficient manner and are medically necessary.

AFMC provides a comprehensive array of review services, including:

  • Utilization review – evaluation of the appropriateness and medical need of health care services and procedures according to evidence-based criteria or guidelines, and under the provisions of an applicable health benefits plan
  • Retrospective review – validation of insurance claims against the medical records after services have been performed
  • Prior authorization – determination of whether a service is medically necessary prior to its delivery
  • Specialty physician reviewers for review of complex coding and billing issues, disputed denials, and development of criteria for new medical and surgical treatments and procedures
  • Quality of care review
  • Education and technical assistance to providers regarding review submissions and quality improvement plans. This service is provided by AFMC’s internal review staff.

The most important points for writing a physician review rationale include:

  1. Provide specific answers to the nurse reviewer’s questions.
  2. State the specific date after which the patient no longer required an acute level of care, or the specific reason the proposed procedure is not medically necessary.
  3. Understand that some of the stay being questioned may be approved and the later days of the stay may be denied. In such case, it is particularly important to state the date after which the patient no longer required acute care.
  4. You may start with a template to include the commonly used wording often required for reviews. But, each review should be individualized to include key elements from the medical record that support your final decision. Case-specific facts confirm that the case was reviewed on its individual merits.
  5. Medicaid Observation status is a billing convention, totally different from Medicare Observation status. Medicaid Observation has a strict 24-hour time limit. It is not based upon the level of care provided.
  6. The time of admission may be a factor in determining whether a patient should have been admitted to observation or acute care. Because of Medicaid’s observation time limit, a patient admitted at 3 a.m. must be ready for discharge by early evening of that day for care to be completed within the 24-hour limit. It is not reasonable to discharge a patient at 3 a.m. the following morning.
  7. The admitting physician must decide between Medicaid Observation or Acute Care status at the time of admission. For this type of review, base your decision on whether it would be reasonable to expect the patient to be discharged in less than 24 hours (in which case the admitting physician is required to use Observation status), or more than 24 hours (in which case the admitting physician could use Acute Care admission status).

The PA Manual, always available online, is a valuable resource when performing reviews. It has specific discussion as to the reasoning behind typical review results and specific examples of phrasing your review that are most appropriate to convey your decision.

Dr. Tinsman is AFMC’s Associate Medical Director.