The Multifaceted Physician Advisor Role

By Andrew B. Maigur, MD, system director, Premier Physician Advisor Program

Traditionally the Physician Advisor (PA) role has existed within the job responsibilities of a chief medical officer (CMO); however, over the past decade or so, this role has evolved into an administrative physician specialty.

Many hospitals and health systems, both community and academic medical centers, are realizing the importance and significance of the PA role. This role continues to be ever evolving and multifaceted.

Utilization Review: A common question I’ve encountered is, “Why do we need a physician to do this job. Shouldn’t the physician be focused on bedside care?” Utilization review is one of the pivotal aspects of the revenue cycle, which requires familiarity with federal and state regulations, clinical criteria used by payers, and clinical acumen of the patient's condition. Determining inpatient versus outpatient status for hospital admissions or elective surgical procedures significantly affect hospital reimbursement.  We must approach secondary status reviews with a clinical eye, understanding the complexity, severity of illness and intensity of services in rendering a recommendation to the bedside provider. We cannot singularly restricted by proprietary clinical criteria used by insurance companies. By being peers, we have an opportunity to provide one-on-one education with bedside providers and hence support and enhance medical necessity documentation in the record. PAs have a strategic position within the organization to identify revenue leakage or process improvement opportunities within the revenue cycle.

Denials Management: Given the fact that insurance companies issue denials for health care services, whether it’s hospitalization or a particular service such as imaging or prior authorization for a surgical procedure, all these decisions are adjudicated on the payer side by a medical director. This lends the PA a unique opportunity to have peer-to-peer conversations with the payer medical director and develop a symbiotic relationship that benefits patients and the health system.

Clinical Documentation Integrity (CDI) and Coding: Clinical documentation in the medical record, when done accurately, has a significant impact on patient care, hospital and physician reimbursement. Providers’ clinical documentation is translated into International Classification of Disease (ICD- 10) codes placed on the claim sent to the payer. These codes affect reimbursement and influence numerous quality metrics that assess the quality of care provided by the health system and the provider. CDI and coding teams often use queries to ask compliant questions to encourage accurate documentation. Unanswered queries or physician questions out of the scope of practice of a CDS nurse are often referred to a PA who helps enhance the query's quality, determining its appropriateness while engaging with the clinical providers in answering questions and providing education regarding CDI. PAs are often intimately involved in clinical validation denials, when payers retrospectively scrutinize the medical record and strip away high dollar diagnoses, subsequently downgrading the DRG and issuing a takeback of reimbursement dollars. PAs actively collaborate with CDSs and coders to appeal these denials and prevent revenue leakage through front-end provider education.

Integrated Care Management: PAs are suitably positioned within the organization to assist with length of stay management, delays in care, care variation among providers, mitigation of discharge barriers, throughput, and post-acute care denials from payers. From readmission initiatives to the challenges of ER boarding, PAs can play an effective role in root cause analysis, problem-solving and process improvement.

Provider Education: Given the above-stated functions related to the revenue cycle, PAs serve as subject matter experts and are enthusiastic about educating and arming the bedside provider with applicable knowledge.

Additionally, PAs are critical in collaborating with contracting teams, providing frontline insights on payer behaviors and building safeguards within payer contracts to stop revenue leakage and reduce back-end administrative costs. Some health systems also employ PAs to assist in the transfer center to train nursing teams and perform medical necessity reviews on non-EMTALA transfers, which positively affect appropriate transfers and reduce out-of-network transfers that undermine patient care and appropriate utilization of costly health care resources. Health systems that participate in CMS bundle payment programs and have value-based contracts with payers employ the expertise of PAs in population health management and risk adjustment documentation. The ACPA has afforded me the opportunity to serve on the Government Affairs Committee (GAC) to advocate for our patients, hospitals, and providers at a federal and state level.

In conclusion, the role of the physician advisor is ever evolving as health systems understand the value that physicians can bring to the table within the realm of the revenue cycle and the business of health care.

Back to the June 2023 issue of Premier Pulse