Background: As the landscape of health care access and delivery has changed over the past 10 years, areas of coding, documentation, denials management, appeals, and reimbursement have become more confusing to navigate for most physicians delivering direct patient care. The physician advisor is an experienced physician who understands the rules and regulatory issues involving patient care and reimbursement, helping the health care system understand what care is medically necessary and how best to utilize hospital resources. The physician advisor knows the intricate details of utilization review, specifically the two-midnight rule and what makes up a qualifying stay for skilled nursing facility placement. These aspects of our health care system are rarely discussed during a physician’s education through medical school and residency training, although they are an expectation of ACGME Common Program Requirements for residents, Section IV.B.1.f).(1).(b).
Purpose: Our physician advisor team developed an educational elective for upper-level residents that introduces them to the basics of utilization review, reimbursement and denials, complex discharge planning, and transfers into our hospital for quaternary care.
Description: The Care Management Physician Advisor team at UNC Hospitals is comprised of 17 experienced physicians with backgrounds in internal medicine, pediatrics, surgery, and emergency medicine. Our team created a physician advisor resident elective in 2019 for a select group of residents interested in learning more about regulatory and payor issues that influence inpatient care. During the pandemic, we shifted this resident elective to a remote learning model, receiving one on one teaching with selected physician advisors via video conferencing. Over the course of a two-year period from 2020 through 2022, there were 19 residents who participated in this one- or two-week elective. Each resident completed a pre-elective survey with two questions focused on the two-midnight rule and the term “qualifying stay” for skilled nursing facility placement. Throughout the elective, each resident had dedicated time to learn about utilization review, complex discharge planning, and the transfer process for patients into our quaternary care academic medical center.
Conclusions: Based upon a pre-elective survey for each of the 19 residents, there were four questions to gauge the understanding of the resident in order to tailor their educational experience. 1) Do you know the two-midnight rule? 2) What are the basics of the two-midnight rule? 3) Do you know what is meant by a “Qualifying Stay” by Medicare? 4) What are the basics of a Qualifying Stay? 18 out of 19 residents had heard of the two-midnight rule prior to the elective, while 68% understood the basics of the two-midnight rule. 68% of residents had heard of the term “qualifying stay”, but only 16% understood the basics of what constitutes a qualifying stay.Our trainee survey results from the physician advisor resident elective identified specific gaps in our residents’ knowledge of the healthcare system that are needed to proficiently operate as a hospital-based physician. Understanding some of these basics should be taught to upper-level residents before completing their residency training to equip them with systems level knowledge.
