APLCM Physician Advisor Standards of Practice and Scope of Services

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INTRODUCTION Over the last decade, health systems are turning to the Physician Advisor role to address regulatory and payer requirements associated with medical necessity, utilization, accurate clinical documentation and appropriate patient status. The Physician Advisor role assists institutions to realize improved financial, quality and patient flow measures that are essential to achieving the goals of value-based care. In the past, a Chief Medical Officer supported these activities within the hospital. Given today’s dynamic health care environment, the need for a specialized Physician Advisor who is readily available to professional staff has moved to the forefront. In addition, the release of the CMS FY 2013 Inpatient Prospective Payment System (IPPS) rule and the 2015 Medicare Outpatient Observation Notice (MOON) created changes for patients, physicians and hospitals. Change and increasing demand have led to an expansion of the Physician Advisor role. The ultimate goal of the Physician Advisor: advocacy for patients and families as well as fellow practitioners for high-value care. A Physician Advisor has a broad base of clinical experience and functions in a variety of roles. These roles include but are not limited to acting as liaison to hospital administration and medical staff; advising professional support staff in their efforts to ensure regulatory compliance; establishing appropriate medical necessity; overseeing specific clinical documentation requirements; educating professional and medical staff; and supporting the achievement of the quality, safety, efficiency, appropriateness, compliance and financial goals of the organization.

STANDARDS OF PRACTICE The Physician Advisor Standards of Practice outline the requirements and competency to function in this role. PROFESSIONALISM The Physician Advisor holds an active medical license and participates in ongoing continuing medical education as required by their healthcare delivery entity to remain up to date on practice, procedures and treatment protocols. Expectations regarding professional conduct include confidentiality, interprofessional collegiality, ethical behavior and a commitment to ensuring high quality, appropriate, safe and compassionate care for all. The Physician Advisor manages conflict of interest issues and recuses self, as needed. LEADERSHIP The Physician Advisor leads by example, is an influencer and acts as a change agent to achieve programmatic goals. The Physician Advisor demonstrates operational effectiveness within the structure of the organization, and advocates for the role of the Physician Advisor within the organization as a catalyst for value-based care initiatives. The Physician Advisor develops organizational knowledge, utilizes and leverages strengths and resources within the organization, and identifies and addresses local and regional factors which affect care delivery. The Physician Advisor provides support for strategic goals and drives behaviors which achieve meaningful and measurable outcomes. The Physician Advisor collaborates with case management leadership.

ADVOCACY The Physician Advisor balances advocacy and support for patients, families, practitioners and professional staff and the organization they serve. ACCOUNTABILITY The Physician Advisor represents the medical staff and medical community standards of practice. The Physician Advisor demonstrates accountability, which is exhibited in a variety of ways: supports performance improvement to drive care management metrics, remains current on healthcare and payor regulatory provisions, provides timely follow up on case prioritization with physicians and care management leaders, attends utilization review meetings and represents care management in hospital-wide initiatives. The Physician Advisor reviews cases as needed to meet criteria for medical necessity, quality, and desired outcomes. The Physician Advisor is responsible for addressing and escalating as appropriate challenging, high conflict or outlier case circumstances, and serves as a mentor for clinical documentation. COMMUNICATION Excellent and timely communication amongst patients, families, care managers, physicians and payors is an important component of the Physician Advisor role. This includes peer-to-peer discussion and clinical documentation opportunities. The Physician Advisor demonstrates the ability to facilitate and de-escalate difficult conversations in a professional manner.

COLLABORATION The Physician Advisor respects and values the contributions of all disciplines and builds relationships that foster trust and confidence. The Physician Advisor demonstrates credibility and problem-solving skills. The Physician Advisor mediates amongst different departments, teams, or individuals involved with the patient’s episode of care. REGULATORY KNOWLEDGE The Physician Advisor aligns and drives performance improvement opportunities within the medical staff and care management team to achieve the highest quality and regulatory compliance. An operational knowledge of CMS guidelines and a keen understanding of the payor market and managed care contracts is essential. CONTINUUM OF CARE PERSPECTIVE The Physician Advisor exhibits an understanding of value-based care models, including a longitudinal perspective of the care delivery focused on the right intervention, at the right time, and in the right care setting. The Physician Advisor works to align all stakeholders across the care continuum. DATA LITERACY Essential to the Physician Advisor role is the ability to identify, interpret, synthesize and apply relevant quality measures to achieve meaningful outcomes. The Physician Advisor leverages outcome data to drive and improve strategic organizational performance and demonstrates expertise in optimizing the electronic medical record.

SCOPE OF SERVICES The Physician Advisor scope of services outlines general expectations of the role and responsibilities. Services delivered by Physician Advisors include: 1. Advocate • Promotes alignment and collaboration with physicians regarding culture, satisfaction, engagement and problem solving • Acts as a liaison to case management, the CMO, professional staff and hospital administration for questions or concerns • Advocates for patient/family-centered care and health equity • Partners with medical and professional staff to promote organizational stewardship of healthcare resources 2. Care Progression and Transitions • Concurrently reviews cases to achieve timely and effective care across the continuum • Participates in case reviews regarding levels of care, length of stay, resource utilization and avoidable delays • Applies clinical knowledge for appropriate length of stay • Supports care management in progressing care to meet length of stay goals 3. Education • Demonstrates up-to-date knowledge of newest technologies, clinical practice guidelines and treatments • Promotes and supports patient safety initiatives • Assists medical and professional staff with education regarding DRG LOS, denials, clinical documentation, practice guidelines within the EMR and any regulatory changes • Drives performance improvement by sharing physician specific data regarding LOS, readmissions, use of hospitalist program, and case denials • Supports education to minimize clinical variability throughout the medical staff • Serves as a resource for CDI and coding specialty

4. Utilization Management • Ensures compliance with CMS conditions of participation and managed care contracts • Drives performance improvement • Participates in Medicare audit reviews • Participates in the appeals process 5. Medical Necessity Reviews and Compliance • Performs clinical reviews on cases referred by healthcare professionals and ensures quality and effective patient care is provided • Advises physicians regarding patient status and appropriate and necessary documentation • Supports efficient patient flow and appropriate patient placement, and effectively coordinates with stakeholders across the continuum of care 6. Clinical documentation • Collaborates with Clinical Documentation team to ensure timely documentation to support working DRG, in compliance with ICD-10 requirements • Follows up with physicians and professional staff to address documentation deficiencies and to update on procedural and terminology changes 7. Certification • Certification validates a physician’s knowledge, competency, and skills. Physicians holding a Care Management Physician Certification (CMPC) credential have demonstrated that they are qualified to provide Physician Leadership in Care Management services within a health care delivery system.


Physicians with 36 months of health delivery system care management experience should have their Care Management Physician Certification credential, CMPC, to practice health delivery system Care Management/Physician Advising. CMPC exam eligibility does not require work experience although a minimum of two (2) years of experience as a physician advisor in care management is recommended.


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