Updated on: December 18, 2018

Physician Advisors: Bridging the Gap Between Confusion and Clarity in Healthcare

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Original story posted on: December 11, 2018

The role has grown in both importance and stature.

Back in 2012, Elizabeth Lamkin, MHA, now chief operating officer for the American College of Physician Advisors (ACPA), wrote an article for RACmonitor titled, “Need a Silver Bullet? Try Adding a Physician Advisor.” Six years later, speeding toward 2019, that idea is more relevant than ever.

The role of the physician advisor, once a niche position within just a few dozen larger health systems, has evolved into an absolute necessity in hospitals of all sizes around the country. Success with physician engagement concerning utilization challenges, improved integrity of the medical record, and positive financial impact within various subsets of hospital revenue cycle have led to an increased demand for trained physician advisors.

Historically, a small sub-set of practicing physicians within health systems slowly and steadily found their way into administrative roles as their interests and personalities led them to participate in various types of committee work. Many of these physicians were the first tagged with the title of physician advisor and in 2013, a small group of them recognized there was an urgent need for education and networking in their rapidly growing specialty. As a result of their efforts, the ACPA was born.

As the healthcare landscape rapidly evolves, so does the scope and importance of physician advisors’ scope of work. Likely from the time the first hospital opened its doors, there has been a tenuous and sometimes challenging relationship between clinical medical staff and administrative leaders. Over time, physician advisors have proven to serve as a critical player, bridging the gap between confusion and clarity within clinical and administrative functions.

Physician advisors don’t simply focus on patient status and insurance denials. They put their interpersonal skills and regulatory expertise to work on a daily basis speaking with physicians and leaders in multiple departments about a variety of complex topics including revenue integrity, clinical documentation improvement (CDI), compliance with Local and National Coverage Determinations (LCDs/NCDs), clinical validation denials and prevention, discharge planning and transitions of care, and readmissions.

As an example, let’s think about the process of a hospital producing a “clean claim.” All aspects of the patient’s stay – from initial access to insurance authorization, assignment of appropriate billing status, verification of accurate clinical documentation and medical coding, and the final drop of the bill for services – are accomplished by at least a handful of different departments within the health system. Mix in the complexity of multiple payers with their own rules and the personalities and workflows of a dozen physician groups and sub-specialties and it is obvious a guiding point of clarity and oversight is necessary. This is precisely where physician advisors come in.

Consider the potential need for a peer-to-peer conversation with the payer’s medical director to secure appropriate billing status. Or, an honest discussion with a surgeon explaining why their patient does not meet billing requirements for inpatient status when a very similar patient yesterday, did. But, as I mentioned before, physician advisors’ scope extends well beyond the arena of billing status.

Throughout the patient’s hospitalization, physician advisors serve as a support to CDI teams to educate providers and secure appropriate documentation. On the back end of the hospitalization, physician advisors are crucial to the revenue cycle team in determining whether a claim is justified and strong enough to defend through the appeal process if denied by a payer. This in turn joins the physician advisor to the payer contracting team and case management department with all involved working together to create clear contract terms and language.

In addition to day-to-day oversight of utilization and billing compliance, physician advisors also serve a vital role in the utilization management committee to review system-wide functions of utilization management and initiate global improvements where needed. This committee actively brings together the clinical and administrative sides of the health system to support effective use of hospital resources.

But, how do physicians from all walks of clinical life obtain the new funds of knowledge required to serve as successful and effective physician advisors? Since its inception, the ACPA’s mission has been to provide this education through online and print offerings in addition to their annual National Physician Advisor Conference (NPAC). For more experienced physician advisors, the American Board of Quality Assurance and Utilization Review physicians (ABQAURP) in partnership with the ACPA, offers certification with sub-classifications available.

As the field continues to expand, sub-specialties within the physician advisor community have developed in recent years including those with a specific focus on CDI, public health policy, and physician advisors working within children’s hospitals. Consolidation of this knowledge base and standards of practice within the ACPA has added tremendous value to healthcare organizations in need of clarity and leadership in navigating the regulatory environment and interpreting concepts for clinical providers.

Physician advisors from large academic centers to small community hospitals across the country will gather March 11 – 13 in Atlanta for NPAC 2019, “Bridging the Gap Between Confusion and Clarity in Healthcare.” Providing 19 hours of CME, NPAC 2019 will start with a pre-conference featuring Ronald Hirsch, MD. His remarks will be directed toward new physician advisors while covering the basics of patient status, medical necessity concepts, regulatory requirements, and overall physician advisor duties.

For case management and utilization leaders in attendance, Kathy Fraser, RN, executive director of the Case Management Society of America (CMSA), will share insights into how case managers can best work with their physician advisors to achieve positive results.

The conference will provide the latest information and current practices required to perform as an effective physician advisor regardless of experience level. Whether you are a physician advisor just starting on your journey within the field, a well-established member of your health system’s teams, or a leader in the C-suite looking for direction on the skills and knowledge your hospital’s first physician advisor needs to exhibit.

To learn more about the conference visit www.acpadvisors.org.


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Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADV

Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADV, is a physician advisor for case management, utilization, and clinical documentation at ProHealth Care, Inc. in Wisconsin. Dr. Ugarte Hopkins practiced as a pediatric hospitalist for a decade. She was also medical director of pediatric hospital medicine and vice chair of pediatrics in Northern Illinois before transitioning into her current role. She is the first physician board member for the Wisconsin chapter of the American Case Management Association (ACMA), a member of the board of directors for the American College of Physician Advisors (ACPA). Dr. Ugarte Hopkins also makes frequent appearances on Monitor Mondays and is a member of the RACmonitor editorial board.

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