Physicians specialize in medicine for various reasons, though primarily to improve patient outcomes by providing more focused care and reducing medical errors. This also allows physicians to see more patients in a period, making them more efficient at delivering quality care. The concept of specialization in healthcare is not new, however it is not always applied to the practice of physician advisory to the same extent that other specialties in medicine are.
Physician advisors are doctors that work in nonclinical roles reviewing medical cases to meet criteria for medical necessity and quality. One of the primary roles of a physician advisor is to ensure compliance and improve patient outcomes by making recommendations on medical necessity. They also possess a unique skill set that enables them to bridge the clinical and financial aspects of healthcare, making them a key component of the revenue cycle. Their skill set is integral in protecting a hospital’s financial health by making level of care (LOC) recommendations to improve reimbursement while ensuring compliance, yet at the same time assuring that the patient receives the most appropriate care.
Physician advisors, as utilization and denial management physicians, are best known for employing the following characteristics:
- Clinical Expertise and Experiential Learning – Physician advisors draw on their clinical experience and training to evaluate complex medical scenarios. Exposure to a variety of cases throughout an advisor’s career, combined with medical knowledge, guides decision-making in second-level reviews and managing denials. This can be difficult for artificial intelligence (AI) to match. Physician advisors integrate multiple clinical data sources such as labs, practitioner notes and images to make recommendations, as well as calling the treating physician for further case clarification. This can be a game changer; AI does not do this. Equally, utilization management physician advisors can add new knowledge from recent cases and quickly understand nuances and context around each case that AI may not be equipped to address.
- Regulatory, Payer and Legal Considerations – Physician advisors can integrate changing regulatory, payer and legal requirements into decision-making. Policies, guidelines and standards can change with little notice, and software systems may not have the ability to adapt quickly. Adherence and compliance to these areas is critical in denial management, as well as in determining the most appropriate LOC during the second-level review.
- Communication and Negotiation – Physician advisors are key in bridging communication between healthcare providers, utilization management teams, medical coders and payers when it comes to denial management. They clarify clinical scenarios and identify missed documentation or explanations to avoid, or overturn denied claims. These human elements of communication and explanation are essential in the overall educational role that physician advisors play, as is the negotiation execution that is fulfilled by the physician advisor during a payer peer-to-peer.
- Critical Thinking and Collaboration – Medical records often lack clear and straight forward documentation of the information required to make medical necessity determinations. Physician advisors are skilled at identifying what may be missing from the medical record to ensure that the patient receives the right care at the right time. Their continuum of care knowledge and collaborative approach to medical case review may trigger them to call the treating physician for additional clarification. Through facilitating an educational discussion with the attending physician, the physician advisor ensures that (s)he has an accurate understanding of the patient’s medical condition to ensure that the medical record aligns with the attending physician’s assessment.
- Reimbursement Optimization – It is integral that health systems protect their revenue with medical necessity determinations, which is a key function of physician advisors. Physician advisors are proficient in making accurate admission status determinations for optimizing reimbursement, which contributes to an overall improvement in quality of care and length of stay. Equally, their role in uncovering the root causes of denials and mitigating them adds to a hospital’s financial success, which is why physician advisors are essential to the revenue cycle.
Explore AppriseMD case studies where their physician advisors have overturned denied hospital stays to increase hospital reimbursement here.