Understanding the Value a Physician Advisor Offers Your Care Team

Understanding the Value a Physician Advisor Offers Your Care Team

Frequently, physician advisors are asked what value we bring to our facility. Physician advisors don’t produce billed services – a benchmark typically used by hospital administrators to measure value. While adequate in the past, those days are long gone. Every payer demands accountability. While not directly producing billed services, physician advisors, a key part of utilization review (UR), provide essential accountability – and can function as force multipliers, if used correctly.

It remains frustrating to hear repeatedly “why are you so expensive? What are you doing? Can’t it be done cheaper?” One wonders who is beating this drum. Is it a hired consultant, promising enticing results? Anyone involved in UR recognizes the gaps in our processes and opportunities to improve. All these areas require more full-time equivalents (FTEs), and subsequently more money, not less, to cover needs appropriately.

Wouldn’t we all like to get better documentation (complete, and directed to diagnoses and treatment), more thorough attention to preauthorizations before admission and surgery, and more aggressive pursuit of denials to get “justice” for the patient and the facility?

While the Centers for Medicare & Medicaid Services (CMS) is trying to close the barn door in January 2024, why aren’t they looking back to bad behavior, even fraudulent, by insurers since 2014? We know they pursue providers and hospitals for clawbacks, as well as fees and penalties, and will continue to do so, going forward. It appears that we are currently too busy with basic duties to emphasize our financial benefits as well as pursue clear opportunities to gain control of our destiny.

Where would we see more bang for our buck? We continue to hear that our signed contracts represent the basic flaw perpetuating our inability to close several drains. I believe that we need to be an integral part of contracting before they are signed, and this must be the main effort of our attempts. “If we are not at the table, we are probably on the menu.” We could affect the financial drain of a short but not exclusive list of the following tasks, which are commonly discussed by executive staff:

  1. Improving the timeliness of preauthorizations and avoiding lack of payment if best efforts are documented;
  2. Obtaining binding, timely authorizations without time locks on appeal, with requested information (protect urgent and emergent as nonnegotiable);
  3. Defining authorization denials as practicing medicine, not negotiating payments;
  4. Preventing readmissions for all causes not being reimbursed, regardless of the absence of association (the heart-failure patient who is hit by a car? Or an inability to appeal unless the amount is over a threshold? Our opponent has an infinite lookback period to nitpick.);
  5. Setting time limits on audits from the insurer or their contracted agents to being cost-free and within six months of submitted clean claims, without using small discrepancies to continue to argue for recoupment;
  6. Limiting audits to one per case, not for a variety of topics;
  7. Limiting prolonged stays in observation and forcing the insurer to truly partner with our facilities to avoid this financial drain on their beneficiaries through copays and hospitals;
  8. Maintaining access to the entire appeal tree;
  9. Allowing batching of claims to control costs and argue variability in claim denials (as seen in a recent malnutrition settlement);
  10. Controlling peer reviews to identifiable physician peers;
  11. Limiting AI-generated denials and limiting the volume of denials to a reasonable time frame;
  12. Mandating adherence to CMS guidelines, though one can expect insurers trying to paint outside the regulations;
  13. Mandating recognition of inpatient-only lists, ambulatory exceptions criteria and Medicare exception criteria for short stays (death, hospice, transfer, against medical advice, rapid improvement). Aren’t they benefiting from the shorter stay, or the handoff to CMS for hospice?
  14. Improving our access to patient advocacy;
  15. Avoiding losing reimbursement for observation services if appeal of inpatient status is unsuccessful;
  16. Obtaining immediate definition of any proprietary guidelines used for denial; and
  17. Ensuring that any contracted item, including proprietary guidelines, cannot be changed unilaterally or without mutual approval.

By limiting the extra demands on our time created by unequal contract terms, physician advisors may have more time to pay attention to helping improve and tighten our pre-hospital authorization, our placement assistance, and more.

Until administration recognizes that our involvement during the contracting step yields dramatic benefit, physician advisors need to emphasize our contribution in compliance, especially on status, for high-weighted Diagnosis-Related Groups (DRGs) and short stays, where audits can be especially costly to facilities. Facing critics, we started a one-day billing hold for Medicare short stays. Rather than affecting timely billing, this hold allowed cleaner submissions to be produced, as seen by recent Livanta audits finding virtually no fault. While not producing money, avoiding costly audits is priceless, and should be seen by the administration as having great value.

Administration needs to only imagine that their internal experts, if properly trained and empowered, can bring value to virtually every hospital activity. Physician advisors protect the hospital against increasingly prevalent audits, prevent contracting away rights placing hospitals subservient to insurers’ whims, and optimize and preserve the billed services, maximizing hospital revenue, ensuring its mission for the future.

I’d like to leave you with my musings from 30 years ago: 

Without Imagination

To seek
and not to find,
to search
and yet see no markers,
To yearn
and have no dreams,
to close one’s eyes
and only see the dark, is to chain
oneself to the cold and empty.

To one
who seeks everything,
who searches everywhere,
who yearns continuously,
and who can see with closed eyes
meadows of wind-swept green,
lakes of rippling blue,
and mountains of towering majesty
There lies the future of man.

Or should I add of the physician advisor.

Facebook
Twitter
LinkedIn

Andrew Markiewitz MD, MBA-Healthcare

Andrew D. Markiewitz, MD, MBA has transitioned from being an orthopaedic hand surgeon to a hospital system physician advisor team member. In the process, he has learned the new world of business that used to be unobserved and behind-the-scenes from most healthcare providers and has realized that “understanding the why” and teaching the reason why will empower any CDI initiatives.

Related Stories

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

2026 IPPS Masterclass 3: Master MS-DRG Shifts and NTAPs

2026 IPPS Masterclass Day 3: MS-DRG Shifts and NTAPs

This third session in our 2026 IPPS Masterclass will feature a review of FY26 changes to the MS-DRG methodology and new technology add-on payments (NTAPs), presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.

August 14, 2025
2026 IPPS Masterclass Day 2: Master ICD-10-PCS Changes

2026 IPPS Masterclass Day 2: Master ICD-10-PCS Changes

This second session in our 2026 IPPS Masterclass will feature a review the FY26 changes to ICD-10-PCS codes. This information will be presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.

August 13, 2025
2026 IPPS Masterclass 1: Master ICD-10-CM Changes

2026 IPPS Masterclass Day 1: Master ICD-10-CM Changes

This first session in our 2026 IPPS Masterclass will feature an in-depth explanation of FY26 changes to ICD-10-CM codes and guidelines, CCs/MCCs, and revisions to the MCE, presented by presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.

August 12, 2025

Trending News

Featured Webcasts

The Two-Midnight Rule: New Challenges, Proven Strategies

The Two-Midnight Rule: New Challenges, Proven Strategies

RACmonitor is proud to welcome back Dr. Ronald Hirsch, one of his most requested webcasts. In this highly anticipated session, Dr. Hirsch will break down the complex Two Midnight Rule Medicare regulations, translating them into clear, actionable guidance. He’ll walk you through the basics of the rule, offer expert interpretation, and apply the rule to real-world clinical scenarios—so you leave with greater clarity, confidence, and the tools to ensure compliance.

June 19, 2025
Open Door Forum Webcast Series

Open Door Forum Webcast Series

Bring your questions and join the conversation during this open forum series, live every Wednesday at 10 a.m. EST from June 11–July 30. Hosted by Chuck Buck, these fast-paced 30-minute sessions connect you directly with top healthcare experts tackling today’s most urgent compliance and policy issues.

June 11, 2025
Open Door Forum: The Changing Face of Addiction: Coding, Compliance & Care

Open Door Forum: The Changing Face of Addiction: Coding, Compliance & Care

Substance abuse is everywhere. It’s a complicated diagnosis with wide-ranging implications well beyond acute care. The face of addiction continues to change so it’s important to remember not just the addict but the spectrum of extended victims and the other social determinants and legal ramifications. Join John K. Hall, MD, JD, MBA, FCLM, FRCPC, for a critical Q&A on navigating substance abuse in 2025.  Register today and be a part of the conversation!

July 16, 2025

Trending News

Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →

CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24