Bridging the Gap: The Role of the Physician Advisor in Revenue Cycle Operations
The need for improved care coordination and population health management makes hospital-physician alignment increasingly important.
Lisa Banker, MD, thinks about her work as a physician advisor in terms of the improvements she can help make in key areas of her organization.
“It’s what makes you feel like you’re making some headway,” Banker said. “If you feel like, ‘I took this problem, and we put a better process in place. We used to get 20 denials a week on this; now, we see none,’ you know you made an impact. It feeds you a little bit and makes you want to keep doing the work.”
Banker is chief medical advisor, value analysis and revenue enhancement for CarolinaEast Health System. In that role, she provides guidance to her physician colleagues on various best practices that contribute to an efficient revenue cycle.
“When I work with physicians, I view myself as being responsible for the bonuses to everyone in the organization at the end of the year,” Banker said. “If we built a better process where there’s a quarter-million dollars that we’re not losing anymore, that’s someone’s bonus.”
Banker presented on the physician adviser role, and how it ties together healthcare clinical and financial interests at HFMA’s 2018 Revenue Cycle Conference. The 2019 conference is scheduled for March 20-22, 2019 (hfma.org/rcc).
Doctor to Doctor
Traditionally, hospitals and physicians lacked incentives to collaborate, Banker said. That is changing with the ongoing shift from fee for service to value-based care. The need for improved care coordination and population health management makes hospital-physician alignment increasingly important.
Physician participation in efforts to improve the value of care is essential, she said, because physicians control most testing and treatment decisions and because physician documentation affects initiatives in domains such as medical necessity and quality improvement. Processes around documentation and status decisions will have less chance of succeeding if physicians are not fully on board.
Even with ongoing hospital acquisitions of physician practices, “Employment does not equal cooperation,” Banker said.
Forging cooperation is the job of the physician advisor, who likely has a better chance to establish a rapport than an administrator without clinical experience.
“Doctors are increasingly burnt out by the environment and the sense that people are always questioning how they do their work and telling them how to do their work and document it,” Banker said.
A hospital may not see immediate and complete physician compliance after bringing on a physician advisor, Banker said, “but at least that person has some credibility with them and can talk their talk. I’m no more intellectually blessed at this information than anybody else, but because it’s coming from a doc, they’re a little more willing to listen. If they don’t show it visibly, it [still] seeps in, and they move on.”
The Right Fit
A physician advisor can be considered part administrator and part physician, and usually is assigned to the finance department, Banker said.
Good physician advisors tend to have the following traits, according to Banker.
- Aptitude in consistently performing revenue cycletasks, such as documentation
- Knowledge of the clinical environment and the associated stresses
- Commitment to learning about the parts of the revenue cycle that involve physicians
- Ability to “talk the talk with passion”
- Comfort in operating outside a physician’s silo
The ideal candidate is internal, a physician who knows the medical staff at least to a degree, Banker said.
The candidate should not be someone who is merely seeking a “golden parachute” job until retirement. “That doc’s not incentivized to do the job effectively,” Banker said. “I’m talking about a full-throttle, full-time approach. You need to find that 45- or 50-year old who’s got enough experience but doesn’t necessarily know everything about this topic.”
The key is personality, Banker said. “The physician who has some charisma and who can interact with the medical staff credibly is a good choice. This person cannot be so abrasive that they’re done at the get-go, but they can’t be a wallflower—they’ve got to be able to hold firm because a lot of times they’re going to be the front face on these initiatives,” Banker said.
Areas of Opportunity
Banker detailed several functions that physician advisors could be expected to perform to boost an organization’s revenue cycle and its bottom line. The physician advisor’s work integrates quality, utilization review, patient safety, and regulatory compliance, Banker said.
Documentation. Physician advisors can support clinical documentation improvement programs, including taking them beyond pure DRG capture to incorporate medical necessity and quality-measure capture. To do that work, the physician advisor needs to understand the principles of value-based payment and other pay-for-performance scenarios.
“To me, the documentation is the basis for everything,” Banker said. “For all the data that’s being gathered for quality measures—it’s all being grabbed, because it’s easy to do, off a claim. No payer or outside auditing entity wants to dig through your chart anymore, they don’t want to read your narrative. They want to see what’s on the claim.
“If you just march it backwards, it’s on the claim because it got coded, and it’s coded because it was documented. So, if your documentation was wrong at the get-go, it kills you right at the root of everything. Doctors are absolutely not taught this in medical school, and we think it’s kind of silly, but you just have to keep chipping away at them.”
Utilization review. Banker thinks more organizations should implement up-front review processes.
“I can’t quite figure out why more of us aren’t grabbing that opportunity,” she said. “If you get [patients] in the correct statuses up front, I think you can save a lot of manpower on the back end. The next day, your utilization review nurses have far less work to do because the status was [correct] up front. Then they can take their efforts and help with progression of care and help remove discharge obstacles and get people out of the system quicker.”
Revenue integrity. In the bigger picture, Banker said, physician advisors are integral to the transition from thinking in terms of the revenue cycle to focusing on the concept of revenue integrity.
The focus shouldn’t merely be “how can we gain this revenue, make sure doctors document diagnoses,” Banker said. “But how can you stem losses and leakage? It’s just as important as trying to gain new revenue.
“I think we’re in a place and space in time where maybe a lot of us have sort of maximized that aspect of things—how much more can we collect? Now we’ve got to focus on our processes, contain costs, prevent leakage, that kind of thing.”
Value analysis. Providers increasingly are focused on making sure they get the best value from their medical spend. Physician advisors can make sure doctors are on board with this effort.
“I see a lot of value-analysis programs, and they’re run by nurses or businesspeople, but to me there’s no visible connection with any physician in that work,” Banker said. Success requires the involvement of someone who can speak to physicians and surgeons about standardization and documentation. “You need that bridge, you need that communication about why it has to shift,” Banker said.
Interviewed for this article:
Lisa Banker, MD, FACP, CCS, CCDS, is chief medical advisor for value analysis and revenue integrity, CarolinaEast Health System, New Bern, N.C.