Potential Role for Hospitalist: Physician Advisor
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While the role of physician advisor in a hospital can be as varied as that of the chief medical officer, depending on the needs of the hospital, there are some universal tasks that leaders in this position perform.
Hospital utilization management (UM) plans are fairly common, as much of their language is set by the Centers for Medicare & Medicaid Services and insurers. These UM plans define the basic roles of a physician advisor. Hospitalists are well-versed in all the areas where physician advisors work in depth.
What do they do?
Completing chart reviews for observation, inpatient status, or medical necessity, working with utilization review (UR) committee physicians to intervene in cases of inefficient resource use, assisting in regulatory compliance, helping with care transitions, managing denials, and aiding clinical documentation teams are some of the more common physician advisor responsibilities. All these roles are easily fulfilled by hospitalists.
Most hospitalists interact daily with a case manager, clinical documentation integrity (CDI) specialist, or physician advisor to answer queries about diagnoses, if the diagnosis was present on admission, if avoidable days are contributing to a length of stay, or if the status could be changed from observation to inpatient (or vice versa).
These close relationships with the clinical documentation specialists, medical records department, and case manager department are important in this role.
Chart reviews are often needed in real time to correct issues such as incorrect status, or if a discharge or lack of discharge requires intervention with the attending.
While coding questions may arise, it’s usually of the query type for the physician advisor (for example: Was this present on admission?), not specific questions on how to code.
Positive relationships with the medical staff are important to the success of this role.
The physician advisor knows that the attending’s focus is patient care, and they attempt to mitigate the administrative interruption to the clinician’s day while making sure that regulatory and documentation requirements are met. The physician advisor role often overlaps with that of the ethics committee as well, as referrals to the ethics committee may involve conflict with patients or families about discharges or utilization of resources.
It’s difficult to describe a day in the life of a physician advisor, as it will differ quite a bit based on the size of the institution.
Those who are administrative full-time equivalents will carve out time daily for chart reviews of extended lengths of stay, attendance at interdisciplinary team rounds, review of second-level referrals from case managers, evaluation and dictation of appeal letters, peer-to-peer reviews with insurance companies, phone calls, and discussions with physicians.
This work can extend into building order sets and helping with note templates to help meet quality and utilization metrics and working with harms committees to ensure documentation and billing are appropriate.
Becoming a physician advisor
The best first step for hospitalists interested in becoming physician advisors is serving on the UR committee at their institution.
UR committee members are partners with the physician advisor, and showing an interest in this work creates a natural succession to an advisor role. Some hospitals have the UR committee chair serve as the physician advisor. While the UR committee chair position could be a volunteer position, physician advisor typically is a paid role.
For a physician also working as a hospitalist, the physician advisor role often is paid at an hourly rate (same as the hospitalist rate) up to a maximum number of hours per month.
Depending on the size of the institution, the physician advisor might also be considered the medical director of clinical documentation. At larger institutions, the physician advisor is a salaried full- or half-time role, while at a smaller hospital, it’s more likely to be a stipend role added to the physician’s other clinical roles.
While being a physician advisor requires no specific training or certification, there are certifications and training available through some professional organizations.
Historically, most physician-advisor education comes from experience on a UR committee, and the queries the physician has been answering for years as a hospitalist.
Most internal-medicine residency training programs have their residents answer queries and perform peer-to-peer calls at times, so even graduating residents have a base for this type of work. Most practicing physician advisors have been developed through mentorship with other physician advisors and with case management and CDI teams.
Challenges of the role
One of the biggest challenges that family medicine or internal medicine hospitalists serving as physician advisors might encounter is that they are called to help make decisions on surgical, pediatric, and obstetrics/gynecology charts, not just medical charts.
This often requires more research on the diagnosis and coding differences in these patient cases to be able to speak to specialist colleagues about utilization recommendations.
While many of these cases are specific, some issues, such as certain surgical procedures becoming outpatient-only (i.e., knee replacements), can be anticipated, with utilization and communication protocols developed to address common queries or denials.
Of course, larger institutions likely will have specific service line physician advisors.
The other main challenge most physician advisors find is the escalating demand for peer-to-peer calls.
While the attending of record may be asked to make these calls, having a physician advisor make these calls offloads this intrusive work from the primary clinician, and allows for some consistency in the approach to the peer-to-peer call.
Having one clinician make these calls also allows for the collection of data learned about insurer practice from these calls, which can lead to tips on improved documentation.
If you’re interested in cultivating some of the skills necessary to become a physician advisor, SHM has a learning portal for UM and CDI developed for hospitalists which may be useful for new physician advisors.
There’s also an SHM Special Interest Group for Physician Advisors. Recent discussion threads included interest in becoming a physician advisor and guidance on that process, as well as more in-depth discussion about specific physician-advisor tasks like peer-to-peer reviews and Office of Inspector General updates.
Dr. Green is the chief medical officer at Paris Regional Medical Center in Paris, Texas.