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By Melinda Young, Author
The physician advisor role, once associated primarily with payers and external vendors, now is seen more in hospitals. These experts can help case managers and other physicians with utilization management, discharge activities, and documentation accuracy.
Health systems increasingly are hiring physician advisors to work in-house to assist with utilization management (UM) and collaborate with case managers in discharge planning. The physician advisor role has evolved in recent years to include mentoring and educating other staff.
The greatest impact of collaborations between physician advisors and case managers exists when the advisors are on-site, says Bruce Ermann, MD, internal physician advisor services (IPAS) at Catholic Health Initiatives (CHI) in Englewood, CO.
“Physician advisors have the ability to combine support, education, and efficiency structure to work within the framework of what case managers need to get through the day,” he says.
External vendors have used physician advisors to remotely review clinical documentation and charges. But some organizations have found it more helpful to evolve from a fully outsourced and remote physician advisor program to an onsite physician advisor program.
Payers were the first to hire physician advisors to examine the medical necessity of procedures and services. Then, hospitals began noticing that this was a job position they needed to fill to help their physicians improve documentation, says Lisa Flynn, MD, MS, FACS, CHCQM, executive of clinical innovation and documentation integrity at Tenet Health in Dallas.
Working for hospitals is rewarding for physician advisors, Flynn says.
“I worked for an external vendor company that did remote review, and so I saw it from that perspective,” Flynn says. “When I’d do the work, I was frustrated; I’d review the case and call physicians who were busy and might be in patients’ rooms, and it wasn’t a great way to educate them.”
Physicians were resistant to hearing ideas from doctors who were not on their medical staff and who didn’t know their health system’s culture and demographics, she adds.
“We need someone onsite who is respected by peers and knows the culture,” Flynn says. “We need someone who can sit in the doctor’s lounge and educate them on regulatory rules, and that was one of the big drivers for us to bring this position in-house.”
There are three chief focus areas for physician advisors, says Linda Van Allen, RN, BSN, CPUM, ACM, vice president of case management and continuing care at Tenet Health:
• Is the clinical review for medical necessity? “Based on the patient’s status, observation, length of stay, and level of care, is the patient appropriate for the intensive care unit versus med-surg, etc.?” Van Allen says. “Those are included in the medical necessity bucket.”
• Is clinical documentation complete and accurate? “In reviewing a case, sometimes there’s a question about medical necessity and if the documentation is complete and timely, supporting medical necessity,” she says. “We’re looking to make sure our documentation accurately reflects what’s going on with the patient.”
• Is the patient’s progression of care timed efficiently? Patients need to be in the hospital for specific services, and physician advisors can help with sequencing and timing patients’ progression of care to optimize quality of care, Van Allen says.
If there is a question or problem with a patient, case managers can go to the physician advisor for coaching and answers, Van Allen says.
“The clinical picture of a patient is different from the case management or social work view, so the physician advisor helps us know what questions to ask, what we need to address with the physician,” she explains. “They’re not only coaching our physicians — they’re coaching our staff, as well.”
For example, Van Allen observed a case at daily rounding where a physician wanted a patient discharged and transferred to inpatient rehabilitation, but the patient didn’t meet criteria for such care.
“So the case manager talked to the physician about it, and he still was very insistent,” she recalls. “We submitted the request to the payer and got a denial, and we asked the physician advisor to talk to the physician.”
The physician advisor explained the alternatives to inpatient rehab and helped the physician understand that the patient would get the care needed elsewhere. “How do we manage to make sure that patient in a nursing home will get the care he needs? That’s the concern, and the physician advisor was helpful in resolving that.”
The physician advisor discovered that the patient’s doctor wanted the patient to receive daily physical therapy and thought the rehabilitation setting was appropriate. An alternative was to transfer the patient to a nursing home that provided weekend physical therapy, she says.
“Case managers can have that conversation with physicians, but if the physician advisor also has that conversation, it helps,” Van Allen says.
Ermann found that his role as physician advisor works well when he meets each morning with case managers after they have handled the early crises and new admissions.
“I make sure they had an adequate opportunity to be prepared for me,” he says. “I ask about their most crucial needs, picking the hottest topic off their plate, and then I find a resolution to that.”
Once Ermann resolves the chief concerns, case managers are more receptive to his priorities, such as handling observation cases or new admissions with questionable diagnoses, he says.
Meetings with case managers help inform Ermann’s later huddles with hospitalists.
“The case managers know a lot more about discharge barriers than hospitalists usually do,” he says. “Case managers may have had conversations with the doctor and may know the patient’s story, but by my knowing that story, I can help the hospitalists.”
Ermann’s involvement often stimulates early conversations about palliative care and goals of care expectations. Instead of waiting until day six of the patient’s hospitalization to bring up palliative care, physicians — encouraged by Ermann — can bring it up on day two.
“Those things improved communication between hospitalists and case managers,” Ermann says. “That improves efficiency — bringing up the issue earlier on.”
Physicians that move to physician advisor roles typically need training and specific education on regulations, documentation, and coding.
“A lot of what we teach is leadership skills — how to effect change management,” Flynn says. “We collaborated with an advisory board to create education and hold full-day orientation sessions for physician advisors.”
At Tenet Health, physician advisors meet daily with the case management director to get an overview of patients’ symptoms and where help is needed, Van Allen says.
“We have daily rounding at all hospitals on every unit that discharges patients, and the physician advisor will attend some of those to address any barriers that come up,” she says. “They intervene and help us get things — physician sign-off or orders for the next day — done.”
When Van Allen reviews cases for medical necessity and encounters problems with payers, the physician advisor might look at the case and contact the payer’s medical director to talk about reaching an appropriate agreement.
Flynn says her role includes educating hospital physicians on how to better document cases.
“We don’t correct their mistakes,” she says. “We educate them on documenting to fully represent the acuity and illness of their patient.”
For example, a doctor may write that a patient is experiencing congestive heart failure (CHF). This is not sufficient for documentation. The physician should note which type of CHF the patient has.
“We teach them to be more specific,” Flynn says. “Chronic CHF is treated differently than acute. So we help educate them to document with the most specificity the acuity and illness of the patient.”
When a payer says the patient is not meeting inpatient criteria, even when the physician knows the patient needs to be in the hospital, it often is because the doctor had been too general and nonspecific in documentation, Flynn adds.
Having a physician advisor there while the patient’s case is being discussed and documented is an effective way to educate doctors, she notes.
Flynn will explain how the doctor’s documentation could be improved, even as she and the physician are standing in front of the patient’s room.
“It sticks with them more than if they heard this in a lecture,” Flynn says. “It’s much more effective to do the education that is just-in-time.”
Financial Disclosure: Author Melinda Young, Author Jason A. Smith, Editor Jill Drachenberg, Editor Jesse Saffron, Editorial Group Manager Terrey L. Hatcher, and Nurse Planner Toni Cesta, PhD, RN, FAAN, report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.