The Physician Advisor’s Corner: What is a Physician Advisor?

Premier Pulse     March 2018 Mar 1, 2018

1114925682By Robert Morrison, MD, associate chief medical officer at Miami Valley Hospital and physician advisor for Premier Health

As we progress from a fee-for-service health care system to a value-based system, we need a doctor with special expertise in reducing inefficiencies, regulatory requirements, and the nuances of payer coverage to help navigate those changes. That doctor is a called a physician advisor.

The physician advisor’s role has been ill-defined in the past, but now is emerging as a specialty of its own – one that integrates quality management, resource utilization, patient safety, regulatory compliance, avoidable care delays, inefficient care, clinical documentation, ICD-10 coding and compliance, education of medical staff and trainees, inappropriate treatments, excessive cost and waste, and uncoordinated transitions of care.

Why does Premier Health need a physician advisor? It all boils down to medical necessity; that is, the need for the patient to be hospitalized. Medical necessity comprises three elements:

  1. Severity of illness – how sick is your patient? Very sick – needs hospital care. Not so sick – could be managed at home. Talk about simplifying a very complicated issue, but it must be assessed every day for every patient.
  2. Intensity of service – the services that the patient requires can only be provided in the hospital. These services are often not what you would think – for instance, nursing care, monitoring, and low-tech treatments are common reasons to hospitalize; while high-tech evaluations and treatments often can be done in the outpatient setting.
  3. The risk of death or an adverse event – if you think your patient will die or suffer serious consequences if not in the hospital, that is a reason to put him or her in the hospital, and a reason to keep him or her in the hospital.

Every day, for every patient, we need to decide whether it is necessary to keep him or her in the hospital. The physician advisor helps us do that with a multitude of tasks, such as:

  • Status determination – inpatient, observation, or outpatient in a bed.
  • Utilization review of our scarce resources – personnel, equipment, and supplies.
  • Length of stay management – assists the care team with progression of the patient.
  • Readmission risk assessment and action plans.
  • Liaison to the insurance companies.
  • Participation in care conferences and huddles.
  • Transition of Care planning – works with the case managers and social workers.
  • Denials management and appeals – peer-to-peer discussions with payer medical directors.
  • Education on documentation and coding.
  • Expertise of CMS regulations and commercial payer contracts.
  • A resource for expertise in compliance with professionally recognized standards of care.

The physician advisor is the doctor you should seek out for any question that is germane to the care of your patient in the hospital. If I can’t answer your question, I probably know someone who can. Over the next several months, I will be addressing some of the major issues pertaining to hospital care in our time. It is no exaggeration to say these issues will affect the health of Premier Health and that of our patients for the foreseeable future. Our very survival depends on our paying attention to these issues, and addressing them in a prudent and expeditious manner.

As for how to get in touch with a physician advisor, the essence of the job is accessibility. We will be at your side to solve any problem you might have in nursing units, in huddles, and at the elbows of case managers, social workers, CSI, and the Clinical Documentation Specialists. We will eventually have a physician advisor present at all sites in the system, but in the interim, please don’t hesitate to pick up the phone and get me involved no matter where you are.

Thanks for reading this – I’ll be waiting for your call.

Bob Morrison

Dr. Morrison is the associate chief medical officer at Miami Valley Hospital and is now the physician advisor for Premier Health. He can be reached in his office or by cellphone:

Robert Morrison, MD
Associate CMO, Miami Valley Hospital
Executive Suite
One Wyoming Street
Dayton, OH 45409

Phone: 937-208-2315 (office) or 937-203-6215 (cell) 

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