Case Management

Mentor moment: The role of physician advisors

Case Management Weekly, August 8, 2012

Health plans have used physician advisors for years. Health plan physician advisors are often consulted upon determination that a physician’s order for an inpatient stay does not meet the health plan’s criteria for covering the stay.   

The health plan generally uses such a review to determine whether documentation of the patient’s clinical condition supports classification of the patient as an inpatient, outpatient receiving observation services, or outpatient. The financial implications of the decision can be substantial, and physician advisors are used as objective parties to intervene in determinations. 

Hospitals use a physician advisor to determine the level of care for both financial and compliance reasons. The level of care decision is complex, and a physician advisor can provide both clinical and regulatory expertise. A physician advisor should:

  • Be educated with respect to applicable regulations and criteria on an ongoing basis
  • Be empowered to address issues with hospital and medical staff members
  • Serve as an educational and compliance resource, both on the global, educational level and on a case-by-case, concurrent basis 

Editor’s note: This article is adapted from Observation Services: A Guide to Compliant Level of Care Determination, Third Edition published by HCPro, Inc.

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