Health systems contract with physicians for administrative work: medical directorships, committee participation, quality programme leadership, call coverage administration. Each arrangement goes through a defined process. The need is documented, the duties are specified, a valuation supports the rate, legal reviews the terms and the agreement is signed before services begin. That part is usually done well.
What happens next is less consistent. The physician performs the work, submits a time log at some point, somebody approves it, and finance pays. Or the physician does not submit a log, payment is made on a standing monthly amount, and the log is assembled later when someone asks. Or the log is submitted to a department administrator, approved informally and filed somewhere that is not the contract record.
When the arrangement is reviewed, internally or externally, the agreement is produced immediately and the attestations are not. That asymmetry is the whole problem, because the compensation is defensible only if the work was performed, and the attestation is the evidence that it was.
Why attestations go missing
The failure is structural rather than careless. Several features of how these arrangements are administered make the attestation the weakest link.
- Payment is not gated on the log, where compensation is a fixed monthly amount, payment runs on schedule whether or not an attestation was received, which removes the only natural forcing function
- Approval sits with the wrong person, logs are frequently approved by a department administrator who has no visibility of the contracted hour limit or the duties specified in the agreement
- The log lives apart from the contract, attestations go to a shared drive, an email folder or a departmental file while the agreement sits in the contract system, so neither record is complete
- Duties are described too generally, where the agreement lists duties in broad terms, the log describes the work in equally broad terms, which makes it weak evidence of anything specific
- Nobody tracks hours against the cap, contracted maximum hours are specified and rarely monitored, so overages are discovered during a review rather than prevented during the year
The surrounding controls, valuation support, signature before performance and term discipline, are the same ones covered in the health system guide to physician agreement controls. Attestation is the piece that has to run every month rather than once at execution, which is why it behaves differently.
A time log assembled months later from calendars and recollection is materially weaker evidence than a contemporaneous record, and the circumstances of its creation are usually apparent from the document itself. The value of the attestation lies substantially in when it was made.
Designing a control that runs itself
An attestation process that depends on people remembering will degrade. The design goal is a control where the default behaviour produces the evidence.
- Gate payment on an approved attestation. Make the approved log a prerequisite for release of payment. This single change converts attestation from an administrative courtesy into a step in a process somebody is motivated to complete
- Route approval to a role with the agreement in view. The approver should be able to see the contracted duties, the hourly cap and the rate while approving. Approval without that context is a signature rather than a control
- Store the attestation on the contract record. Attach each approved log to the agreement it supports, so that producing the evidence for a review is a report rather than a search across departments
- Track cumulative hours against the cap. Show hours to date against the contracted maximum on the agreement record, with an alert before the cap is reached rather than after it is exceeded
- Require specificity proportionate to the duties. Where the agreement specifies duties with precision, require the log to reference them. Generic entries such as administrative duties provide very little support for the payment they justify
A five-step way to close the gap
Step 1, Inventory the arrangements and their current evidence
List every active administrative services and directorship agreement and record, for each, whether attestations exist for the current year and where they are held. The inventory alone usually identifies the arrangements needing immediate attention.
Step 2, Standardise the attestation form
Use one form across arrangements, capturing date, duration, service description referencing the contracted duties, and both signatures. Variation in format is a significant part of why these records are hard to assemble.
Step 3, Connect payment to approval
Work with finance to make an approved attestation a condition of payment release. Expect resistance where compensation is a fixed monthly amount, and treat that resistance as the point: a fixed payment with no performance evidence is the exposure.
Step 4, Put hours and cap on the contract record
Make cumulative hours visible against the contracted maximum, with alerting ahead of the limit. This prevents the overage conversation rather than documenting it.
Step 5, Review a sample quarterly
Pull a sample of arrangements each quarter and check that attestations exist, were contemporaneous, were approved by the right role and are consistent with the duties. Quarterly sampling keeps the process honest at modest cost.
Attestations attached to the agreement
Aavenir holds time logs, approvals and cumulative hours against each physician arrangement record.
What reviewers actually look for
Reviews of physician administrative arrangements follow a predictable sequence. The agreement is requested first, and it is almost always produced, properly executed and supported by a valuation. The second request is for evidence that services were performed, and this is where arrangements separate into those with a running attestation process and those without. Reviewers look at whether logs exist for the period, whether they were created close to the work rather than in a batch, whether the described services match the duties in the agreement, whether an appropriate person approved them, and whether total hours stayed within the contracted maximum. They also look at whether payment was made in periods where no attestation exists, which is the finding that tends to generate the most follow-up. None of this requires sophisticated systems. It requires a standard form, a gate on payment, storage against the contract record and a visible hour count. The arrangements that fail review are rarely the ones with weak agreements; they are the ones where the agreement was the end of the process rather than the beginning. A related point is worth making about volume. Health systems commonly run many of these arrangements at once, often several hundred across a region, and the ones that fail are rarely the largest. They are the small, long-standing directorships that renew automatically, attract no attention, and have had no attestation filed for years because nobody noticed the payments were still running.
Attestation elements and why each is examined
Each element of a time log answers a specific question a reviewer will ask. Logs that omit one of them tend to be challenged on that point.
| Element | Question it answers | Weak form | Strong form |
|---|---|---|---|
| Date and duration | When and how much | Monthly total only | Per-session entries with dates |
| Service description | What was done | Administrative duties | Named duty referenced to the agreement |
| Physician signature | Who attests | Typed name on a summary | Signed per submission period |
| Countersignature | Who approved | Department filing only | Named role with agreement in view |
| Cumulative hours | Within the cap | Calculated at year end | Running total on the contract record |
The administrative burden of a working attestation process is small, a form, a gate and a place to put the record, and it is almost entirely front-loaded into setting the process up. The alternative is reconstructing evidence under time pressure for arrangements that were correctly structured and poorly documented, which is both more work and considerably less convincing. Our healthcare obligation management datasheet covers the wider commitment set these arrangements sit within.
For related guidance, see Provider contract management for health systems, GPO and medical device contract control for health systems and Value-based care contract administration, simplified.
