Embrace Your Physician Advisors’ Potential

The role of physician advisors has evolved into an absolute necessity in hospitals of all sizes around the country. As the healthcare landscape rapidly evolves, physician advisors have proven to serve as critical players, bridging the gap between confusion and clarity within clinical and administrative functions.

The role started as a loosely defined physician champion for case and utilization management teams. Only one or two individuals on a hospital’s medical staff generally gravitated to this position, usually as they were winding down in their career and looking to work fewer clinical hours. But, with the arrival of the Medicare Inpatient-Only list in 2000, nationwide Recovery Audit Contractor (RAC) audits in 2009, and creation of the Medicare Two-Midnight Rule in 2013, a new spotlight on hospital compliance, with mandates related to Centers for Medicare & Medicaid Services (CMS) rules and regulations, came into being.

As more and more physicians became well-versed in hospital service utilization, payment structures, and potential penalties related to compliance and quality metrics, these individuals moved beyond serving as mere support for nurse case and utilization managers. They were tasked with translating CMS requirements and payor guidelines about medical necessity and documentation to their colleagues in a way they could understand and put into practice. While undoubtedly frustrating, it increasingly became clear that a message about “the business of medicine” delivered to medical staff by a physician was received much more readily than the same message conveyed by a non-physician. 

In 2014, a number of these individuals – now with the common title of Physician Advisor – came together to form the American College of Physician Advisors (ACPA). This nonprofit, physician-led organization is now home to over 1,200 members, and serves as a testament to the evolution of the field. Physician advisors are now experts for adult and pediatric populations not only in case and utilization management, but also clinical documentation integrity, population health, quality initiatives and strategies, and much more. This role is an essential part of Condition Code 44 and W2 processes, which cannot be overlooked, from a compliance perspective. When considering hospital viability, in light of aggressive payor tactics involving medical necessity denials and DRG downgrades, physician advisors are particularly effective working with utilization management (UM) and clinical documentation integrity (CDI) leadership, in collaboration with medical staff.

While the role of physician advisor began as perhaps only one individual in a hospital who took on the rapidly growing needs of case and utilization management departments, a new staffing model has recently grown in popularity. More and more, hospitals are attempting to fulfill their needs by employing multiple physicians in fractions of full-time equivalents (FTEs) devoted to the physician advisor role. Instead of one physician working full-time, five rotate over the course of the month, assigned only 0.2 FTE for the efforts. Often, this leads to significant reduction of the focus and level of expertise provided by these physician advisors. Juggling patient care and potentially one or two other administrative roles can prevent these physicians from developing the level of expertise and familiarity they need to effectively function as a physician advisor. Especially in situations where they are never working with 100-percent focus on their physician advisor role – for example, when the vice president of medical affairs or medical director of a large hospitalist group is also serving as the physician advisor – it is almost impossible to address status escalations in a timely fashion or find time for creation and provision of routine education for medical staff and UM teams. 

If a hospital feels they can’t secure full-time physician advisors because there are individuals within the organization who are genuinely interested in the role, but aren’t ready to give up their clinical work, they should establish a full-time lead or chief physician advisor. This role will serve as the glue and ringmaster for the hospital’s physician advisory efforts, ensuing there is a consistent go-to person all staff is familiar with and relies on, no matter what the situation, day of the week, or time of day. Free from secondary review escalations, this individual can focus on studying data related to metrics such as medical necessity denials by payor according to primary diagnosis, readmissions, and utilization of Condition Code 44 and W2. The lead would also be responsible for ensuring the continuous education and proficiency of the other physician advisors on the team, including providing onboarding and mentoring support when new members are added.  As physician advisors become exponentially more common and valuable within hospitals and health systems, it’s important to understand how their impact can be inadvertently diluted through FTE spread. Consider combating against this by establishing a full-time lead physician advisor, or mandating that each physician serving in the role works at least 0.5 FTE, to ensure persistent mastery of and focus on the subject matter.