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Medical Necessity Reviews and Compliance
Physician advisors conduct second-level medical necessity reviews for patient cases that do not meet first-level screening criteria or do not have a documented expectation of length of stay. They also provide recommendations on inpatient admissions, outpatient and observation services, or cases not deemed appropriate for hospital-level services.
Physician Champion
As a physician champion, physician advisors consult with providers, particularly when difficult issues arise, and have critical conversations concerning resource utilization and medical necessity.
“Besides case management and utilization review, the physician advisor may also work with the clinical documentation improvement team to capture the appropriate ICD-10 codes to ensure documentation reflects the clinical complexity of a patient’s care so hospitals can bill appropriately for services,” says Wetch. “They help make medical records audit proof from a coding and medical necessity perspective, to ensure accurate reimbursement.”
Denial Management
Physician advisors conduct peer-to-peer discussions with the commercial payer medical director for cases that have been denied. Resolving medical necessity issues prior to a claim submission saves hospitals rework and maintains cash flow since fighting a denied claim can be a lengthy process and involve much rework.
Length of Stay Management
Physician Advisors assist case management with length of stay reviews and facilitate discussion with the attending physician in cases where there is no progression in the plan of care, an ambiguous plan of care, or where there may be an ability to arrange for a plan of care at an alternative level.
“Physician advisors help ensure patients are in the hospital when they need to be and not when it's appropriate to release or move them to another care environment, such as a skilled nursing or acute care facility, home health, or outpatient observation services,” says Wetch.
Education
Working side by side with case managers, physician advisors give direction to and training on patient process flow, and offer guidelines about level of care, length of stay, readmissions, and other utilization issues. They also serve as an educational resource for hospital staff regarding medical necessity and regulations.
To do their job well, physician advisors must keep abreast of all pertinent federal and state regulations, laws, and policies and facilitate dissemination of relevant information to hospital clinical staff when appropriate.