Posted: 8/24/2019

One question posed at the 2019 National Physician Advisor Conference was: “What will Physician Advisors do if the concept of Inpatient vs. Observation goes away?” R. Philip Baker, MD, Medical Director of Case Management at Self Regional Healthcare responds with his thoughts.

The role of the Physician Advisor is rapidly evolving into an integral part of the modern hospital’s armamentarium in dealing with the rapidly changing healthcare environment. Once relegated to status determination to be sure that each patient was in the correct status while in our facilities to ensure the correct reimbursement, that is now becoming a minor component of the contribution the Physician Advisor makes.

Physician Advisors are integral to improving every aspect of hospital performance. We contribute in three areas in particular: revenue cycle, quality measures, and Clinical Documentation Integrity (CDI). The modern Physician Advisor has a role to play in each of these areas with many of us responsible for a specific focus.

Revenue cycle impacts are vast and for the purpose of this article will only be highlighted. Status determinations have a direct positive impact on immediate reimbursement and prevention of denials. Concurrent peer to peer discussions can likewise prevent denials that require considerably more work and delay payment. Denial prevention is a huge area of involvement for Physician Advisors. Many of us are directly involved in writing appeals to fight commercial and managed plan denials and take it a step further to reach out and provide service line education to medical staff on why the denials are occurring. Additionally, all zero to one midnight Inpatient stays for patients covered by Fee-for-Service (FFS) Medicare should be reviewed in some fashion to ensure compliance with the Two Midnight Rule. Actively assessing DRG downgrades and clinical validation denials is also important to ensure payors utilize correct definitions of diagnoses and follow AHA Coding Clinic Guidelines.

Many Physician Advisors focus on length of stay issues and discharge barriers to address unsuported utilization of hospital services. Ultimately, the Physician Advisor is in a unique position to build relationships with the payor medical directors to address issues between plans and health systems and help resolve problems. Physician Advisors are often involved in quality improvement. Review of Patient Safety Indicator (PSI) cases ensures that coding is captured correctly and that potential care issues are addressed. Reviewing readmissions can lead to hospitals understanding what factors are most problematic, from availability of follow-up care following discharge to testing available on weekends.

Educating your hospital’s medical staff on how to document accurately and completely has tremendous impact not just on revenue cycle but also on quality metrics by correctly risk-adjusting the patients. Many Physician Advisors work closely with Clinical Documentation Integrity Specialists to ensure physician compliance with addressing queries and provide ongoing education in the proper use of terms.

This article is not an all-inclusive list of the many impacts a Physician Advisor can have on a facility, but a call to arms to be involved in multiple areas within your institution if you are not already. As more facilities employ full-time Physician Advisors, we will see even more areas of involvement. For most of us, it is not a matter of if we can get involved but rather a matter of learning to say no to some of the tasks we are asked to participate in to be able to digest the multitude of things already on our plate.

Those of you who are new to this world may see this as overwhelming. But, take heart as very few of us came into this arena with any knowledge of where we were going. This profession is rapidly evolving and will continue to do so with changes in healthcare reimbursement and the move to value-based care and population management. Dive in, the water is great! And, though at times the currents can be tricky, all of you can be Olympic athletes in the world of Physician Advisors.