In recent years, healthcare professionals have faced increasing pressure to provide high-quality care to optimize payment. Simultaneously, they have had to strive to reduce inefficiencies in patient throughput and healthcare delivery to comply with regulations promulgated by government and commercial payers.
Many physician leaders have been performing functions in pursuit of these goals at their institutions, but these functions can be formalized under the purview of a dedicated physician adviser. The role, which had been ill-defined, is now recognized as an emerging and growing subspecialty within the medical field—one that integrates quality management, resource utilization review, patient safety, and regulatory compliance.
Physician advisers traditionally focused on leading utilization review committees and providing status reviews for observation, inpatient, and extended-stay patients. Often, facilities have outsourced this function to third-party vendors due to the lack of internal expertise. However, especially since the advent of Medicare’s two-midnight rule, outsourcing this work tends not to achieve the level of engagement required to coach physicians on regulatory best practices.
It is no longer enough to simply follow established guidelines to determine inpatient or outpatient status. This task presents an increasing demand to patient financial services, the business office, physicians, and utilization management staff.
To add to the difficulty, traditional Medicare and Medicaid patients follow one set of guidelines while commercial and managed-Medicare patients typically have another set based on individual facility contracts or unique payer rules.
A Multipurpose Role
CFOs and revenue cycle teams are noting the impact and ROI that a trained physician adviser can bring to their organizations as a clinical partner to investigate the operational aspects that produce balance sheet concerns. A trained physician adviser can be the principal investigator and a change agent commissioned by a CFO to embed within a hospital’s medical staff, care management department, and mid-revenue cycle team, thereby getting into position to identify operational deficiencies.
Areas of operation in which an internal physician adviser can contribute include:
Utilization reviews: Assess medical necessity for admission, use of professional services, blood product and medication stewardship, length-of-stay/extended-stay scenarios, high-risk patients.
Denial management: Examine denial trends. Assist with appeals (peer-to-peer and formal written appeals) and development and implementation of action plans for denial prevention.
Length-of-stay and readmission-reduction initiatives:Capture avoidable days and delays. Identify trends that produce variations in care. Collaborate to remove barriers to inefficient or inappropriate care or discharge.
Care management and team-based care: Make daily interdisciplinary rounds. Ensure progression of patient care during hospitalization and that post-discharge supports are in place as needed to deliver a smooth discharge. Assist providers in accurately documenting the patient’s medical course to improve continuity of care.
CDI and coding departments: Help reduce discrepancies in diagnosis. Capture appropriate comorbid conditions.
Insurance regulations and compliance team: Educate providers. Monitor and prevent noncompliant actions that can result in loss of payment.
Practitioner education: Provide education to medical students and to attending physicians, nurses, therapists, coders, and billers.
Quality management processes: Identify processes that can be streamlined to improve patient outcomes, reduce length of stay (while maintaining the quality of care and patient safety), and optimize payment.
Health plan contracts: Ensure appropriate terms for timely medical-necessity review as well as fair and consistent appeal processes.
Other: Assist in promoting patient safety and addressing patient and family concerns. Partner in installing palliative care initiatives.
A New Network
In 2014, the American College of Physician Advisors (ACPA) was launched, establishing a not-for-profit, peer-driven network for the growing physician adviser community.
The ACPA now serves as a central hub for networking and discussion among multiple medical disciplines, and provides open forums for the exchange of information that can be tailored to any physician adviser’s home facility—including the most extensive physician adviser training curriculum and only board certification pathway, in partnership with the American Board of Quality Assurance and Utilization Review Physicians.
Ven Mothkur, MD, CHFP, MSc, is corporate physician advisor, Franciscan Health; board member, American College of Physician Advisors (ACPA); and chair, Governmental Advisory Committee, ACPA.