When many physician advisors began their careers 10, 20, or even 30 years ago, their focus involved communication. Communication between case and utilization managers and medical staff, first and foremost, but also between leaders of these departments and hospital executives.
Physician advisors have persistently served as bridges between two, admittedly broad categories of individuals within health systems: Those who have vast medical knowledge but little business or operational knowledge, and those whose breadth of expertise is the reverse.
Trusted, timely, and reliable communication grew even more important with the enactment of the Medicare Two-Midnight Rule in late 2013 as hospitals were suddenly faced with audits, citations, and financial penalties from the Centers for Medicare and Medicaid Services (CMS). Physician advisors’ skill as effective communicators quickly morphed them into outright educators related to the specifics of patient statusing, medical necessity, and hospital service utilization.
Next came collaboration with clinical documentation integrity (CDI) teams to ensure queries were addressed by medical staff in a timely manner and also, again related to the role as educator, translating coding requirements for capture of specific diagnoses in the electronic health record in a way doctors can understand.
Most recently, as Medicare Advantage enrollment ballooned with more and more payors utilizing some form of automated algorithms or artificial intelligence to deny cases for Inpatient status, the world of addressing payor denials via peer-to-peers (P2Ps) and written appeals has grown exponentially within the last five years. Once an occasional or strategic move to fight particularly egregious or high-dollar cases, the deluge of denials with associated P2P opportunities has led some hospitals to aggressively engage to fight off the onslaught. Physician advisor participation in P2Ps has led to the most black-and-white representation of the role’s return on investment (ROI) for hospitals and health systems.
Unlike ensuring compliance with CMS Conditions of Participation (CoPs), preventing avoid days by heading off delays in discharge due to patient request, or steadily decreasing the number of Condition Code 44s and W2s by teaching admitting clinicians how to use the Two-Midnight Rule, there is a clear “A + B = C” breakdown of the financial benefit associated with P2Ps. Unsurprisingly, this has resulted in many physician advisors watching their day-to-day responsibilities shrink to an almost singular focus – fighting payor denials via engagement of the P2P process.
While this might prove to be the clearest demonstration of a physician advisor’s ROI, it absolutely can’t be their only responsibility. Shifting their spotlight to denials and P2Ps leaves a vast swath of the other important work physician advisors have historically led or at least been an integral part of. Unfortunately, many hospitals and health systems don’t recognize the compliance and operational risk associated with removing their physician advisors from this kind of work until it’s too late. This can result in escalating Observation rates and/or short stay Inpatient rates, declining collaboration between medical staff and utilization/case management teams, and increased presence of sub-standard documentation. Instead of allowing your physician advisor or physician advisory team’s prior successes disintegrate into dust, consider modeling the clinical division of scope via sub specialization.
As identified for many years by the American College of Physician Advisors and other experts in the field, standard physician advisor coverage of case and utilization management needs – including CMS rule compliance, education tailored to clinicians, case managers, utilization managers, and bedside nurses to name a few, and close collaboration with case/utilization management teams as their clinical champion – is one physician advisor per 250 hospital census. It’s important to note this doesn’t include participation in P2Ps or comprehensive collaboration with and support of the CDI and coding teams. While in years past, solo or even system physician advisor programs could manage the bandwidth of participating in a few P2Ps a week and addressing a handful unanswered CDI queries in addition to their case/utilization management duties, this is no longer possible due to the sheer volume of medical necessity and clinical validation denials seemingly sent by all payors, all day, every day.
Hospitals are finding that opportunities related to fighting these denials in addition to the ever-present need to ensure compliance with the CoPs require the evolution of specialized physician advisory roles. While the traditional 1/250 coverage for CM/UM responsibilities remains the same, additional bandwidth is required based on volume and modality of addressing denials and pursuing P2Ps. Depending on volume and method of assessment prior to reaching the physician advisor, this could easily support at least an additional 0.5 FTE for a P2P physician advisor serving a 250-bed hospital. Similarly, additional FTEs could be beneficial for dedicated support and collaboration with CDI teams related to targeted education to medical staff about Case Mix Index (CMI), creation of unified clinical definitions, and review of mortality and quality metrics.
Instead of attempting to maintain the traditional scope of physician advisory function and leadership while cramming in a half dozen or more P2Ps a day and squeezing in whatever spare time might be left in the week to optimize CDI initiatives, consider this alternative. It will allow your physician advisors the appropriate focus and attention to their work and specialization in each designated role will ultimately foster pointed expertise and mastery.
