In an era of declining reimbursement, new Medicare regulations, and ICD-10 implementation, a growing number of hospitals have enlisted the services of a Physician Advisor to address critical administrative concerns.
For those unfamiliar, the physician advisor is a physician with a broad base of clinical experiences who acts as a liaison between the hospital administration, clinical staff, and support personnel to ensure compliance with regulatory issues, advise physicians on medical necessity, and help the leadership team reach overall organizational goals related to the efficient utilization of health care services.
"The physician advisor is a key position for a hospital," says Jo Wetch, director of consulting and physician advisory services for Schumacher Clinical Partners. "Among other duties, this person runs interference for the hospital staff, tackling health care policy issues that could otherwise divert providers' attention away from patient care.”
Regarding the role's evolution, Wetch adds, "In the old days, we referred to this role as the medical director of utilization review. The term physician advisor was introduced by companies that delivered remote advisory services to support hospital case/utilization management teams. Over the years, it grew into a full-time, in-house position that hospitals are beginning to embrace."
Physician Advisor's Role
The physician advisor's role comprises the following areas of responsibility:
Medical Necessity Reviews and Compliance
Physician advisors conduct second-level medical necessity reviews for patient cases that do not meet first-level screening criteria or do not have a documented expectation of length of stay. They also provide recommendations on inpatient admissions, outpatient and observation services, or cases not deemed appropriate for hospital-level services.
As a physician champion, physician advisors consult with providers, particularly when difficult issues arise, and have critical conversations concerning resource utilization and medical necessity.
“Besides case management and utilization review, the physician advisor may also work with the clinical documentation improvement team to capture the appropriate ICD-10 codes to ensure documentation reflects the clinical complexity of a patient’s care so hospitals can bill appropriately for services,” says Wetch. “They help make medical records audit proof from a coding and medical necessity perspective, to ensure accurate reimbursement.”
Physician advisors conduct peer-to-peer discussions with the commercial payer medical director for cases that have been denied. Resolving medical necessity issues prior to a claim submission saves hospitals rework and maintains cash flow since fighting a denied claim can be a lengthy process and involve much rework.
Length of Stay Management
Physician Advisors assist case management with length of stay reviews and facilitate discussion with the attending physician in cases where there is no progression in the plan of care, an ambiguous plan of care, or where there may be an ability to arrange for a plan of care at an alternative level.
“Physician advisors help ensure patients are in the hospital when they need to be and not when it's appropriate to release or move them to another care environment, such as a skilled nursing or acute care facility, home health, or outpatient observation services,” says Wetch.
Working side by side with case managers, physician advisors give direction to and training on patient process flow, and offer guidelines about level of care, length of stay, readmissions, and other utilization issues. They also serve as an educational resource for hospital staff regarding medical necessity and regulations.
To do their job well, physician advisors must keep abreast of all pertinent federal and state regulations, laws, and policies and facilitate dissemination of relevant information to hospital clinical staff when appropriate.
Physician Advisor Qualifications
"A person qualified to fill the role needs to be a good communicator, someone skilled at building interpersonal relationships who can work with everyone from hospital administration to clinical staff to other service providers," Wetch says.
"It also requires someone with a core body of knowledge and a broad range of clinical experience who is well-versed in hospital process and flows. Emergency medicine and hospital medicine physicians are ideal for this because they understand the inner workings of the hospital."
Wetch also emphasizes the need for respect from medical staff as a necessary quality:
“Otherwise, doctors and clinical staff may be less inclined to heed the advisor’s advice — a fact that is particularly true of remote physician advisors with whom the staff has no relationship,” she says.
Other qualifications include expertise in utilization management, regulation compliance, and clinical core competencies (or a willingness to learn if not already qualified).
Why Be a Physician Advisor?
Although they function in a non-clinical capacity, physician advisors still have a significant impact on patient care, albeit more indirectly through their interaction with doctors and staff.
They also have the opportunity to not only make a difference in other physicians' careers but also on their own as hospital administrators, CMOs, VPMAs, or other leadership positions. On a personal level, they are afforded better work/life balance as their job does not typically require night and weekend shift work.