Physician advisors should be involved in far more than secondary status reviews and peer-to-peer calls. They must stand out as leaders, resources, and champions of their case and utilization management teams, and be recognized as educators and problem-solvers for their hospitals’ medical staff. If you’re a physician advisor and this doesn’t sound like your role, or if you work with a physician advisor, but this description is way beyond their professional line of sight, it might be time to reconsider the position’s goals and requirements.
There are many iterations, facets, and ranges of scope involving the physician advisor role within hospital settings. But one thing should be clear: when addressing escalations from case or utilization managers about real-time patient status, physician advisors must understand the Medicare Two-Midnight Rule inside and out. This includes the exceptions, how MCG or InterQual criteria fit in, and a firm understanding of the Centers for Medicare & Medicaid Services (CMS) definition of “medically necessary hospital care.” Physician advisors should be their hospital’s expert and trusted resource about the Rule, ready to answer questions from anyone within any department in the hospital or health system.
This knowledge should not be kept to themselves. It is imperative for physician advisors to educate their admitting clinicians about the Rule. Why? Because of the Code of Federal Regulations, Title 42, Chapter IV, Subchapter B, Part 412, Subpart A, 412.3: “…an individual is considered an inpatient of a hospital, including a critical access hospital, if formally admitted as an inpatient pursuant to an order for inpatient admission by a physician or other qualified practitioner…the order must be furnished by a qualified and licensed practitioner who has admitting privileges at the hospital…who is knowledgeable about the patient’s hospital course, medical plan of care, and current condition. The practitioner may not delegate the decision (order) to another individual who is not authorized by the State to admit patients, or has not been granted admitting privileges applicable to that patient by the hospital’s medical staff.”
The Code is very clear: clinicians are required to understand the Medicare Two-Midnight Rule and appropriately assign their patients to inpatient or outpatient status with observation services. True, this status-determining modality won’t be appropriate for everyone – for example, patients covered by commercial plans – but it will compliantly capture those covered by Medicare.
What about utilization or case managers? Shouldn’t they assist with status determination efforts by providing guidance to clinicians when needed? Absolutely – which is why physician advisors should also ensure that they educate these teams. The goal is not for the utilization managers to direct the status decision to the clinicians and expect a blind co-sign of an inpatient status or observation service order. They should serve as an extension of the physician advisor when working with medical staff, enforcing and amplifying their knowledge about the Medicare Two-Midnight Rule and medical necessity. Only after a physician advisor has comprehensively and routinely provided education to utilization managers and clinicians alike can the two teams work collaboratively to assign appropriate patient status at the time of hospitalization, and in the following 24-48 hours.
While they may not remember or even be aware of everything pertinent from a utilization and case management standpoint, when it comes to CMS rules and regulations, physician advisors should be well-versed in how to find the answers, when asked. Additionally, they should understand how specific processes they are involved with relate to the Conditions of Participation, conditions for coverage, and so on.
If something is going awry within case or utilization management, if a step is missing within a CMS-mandated process, or if it’s discovered that there is misunderstanding about a concept within a specific group or involving a single individual, physician advisors should be all over it.
No, they cannot boil the ocean or right every wrong. But as leaders, experts, educators, and collaborators, they should persistently strive to offer solutions or make corrections. Under essentially every circumstance, physician advisors are most effective when working in lockstep with their partners in case and utilization management leadership.
Like the partnership with medical staff, persistent and routine communication and collaboration is a must.
Even if “only” participating in their hospital’s peer-to-peer process, there is much to gain here as well, if a physician advisor is truly invested. Is the initial denials assessment process as efficient as it should be? Are the qualifiers directing the decision of which cases are escalated to peer-to-peer versus which are re-billed as observation, producing favorable results? Track and assess outcomes on a routine basis, and consider how stausing efforts might be influencing the trends.
If there’s an opportunity for improvement or conflicting concepts leading to suboptimal results, the physician advisor should take the lead on brainstorming a corrective or alternative course of action with their utilization, denials, and even medical-staff partners.
Physician advisors are team captains and should demonstrate passion and dedication for their role, thriving when collaborating with all members of the hospital’s care and administrative teams.
