How to become a physician advisor to do Utilization Reviews?

Do you want to get ready so that you can jump in when an opportunity comes your way and do Utilization reviews?

If you want to do UR work, you may have to cut down on your clinical work. If you are looking for work from home, this is a good option. It allows more flexibility to your time.

You will need to talk to other reviewers from insurance company or doctors from hospital depending on for whom you want to work. If you work for hospital, you can involve yourself in writing appeals for denials, doing Code 44s, downgrading or upgrading patients, educating the peers about documentation etc.

Personal Finance principles say that we should always have more than one source of income and this kind of work fits well with that principle as you can do this if you want to do this during your off week.

Most hospitals or insurance companies want a few years of clinical experience before you can venture into this work.

You can start your preparation towards getting ready to do UR work in future by first joining and serving on committees for Utilization Review, Peer Review, Quality improvement and Safety in your current hospital.

Tell your Medical Director that you are interested in becoming a Physician Advisor so that when opportunity in the form of education or actually requiring a Physician Advisor opens up, they will have you in their mind. It is like reserving a spot.

The first source of information that can be very useful to prepare you for doing UR is RACsummit.com. This is a boot camp for physician advisors who want to do the UR work. In my view, this is a must for everyone unless your hospital that you work for has their own training program.

This RACsummit gives valuable information about Medicare advantage plans and how they function. It also gives info on how to do peer to peer reviews. You can attend in person or you can buy subscription and listen to their lectures online. It hardly takes couple of days to listen to those lectures.

You can also get MCG Care guidelines certification in Utilization Management. Your hospital must be able to license the MCG solutions Inpatient and Surgical Care and General Recovery Care for you to be eligible for this certification. You can reach out to MCG at [email protected] and ask for application form. Once you pay their exam fee of $150, you can watch videos and prepare for their certification exam.

You can also take membership at American College of Physician Advisors which has an education section in their website and you can attend their annual conference too to learn more. You can also attend other physician advisor conferences which you can find by searching online.

You can also join NAPA (National Association of Physician Advisors). Joining these organizations and attending their conferences or reading the education material on their websites will help you to learn the language, scope and practice of Utilization reviews.

An other great resource that you can use to learn on an ongoing basis is MonitorMondays Podcast.

All the above are not compulsory. They are options available to prepare you well. Each hospital or company have their own requirements and training programs.

For those who want to work for your hospital in Utilization Management dept: In most hospitals, the nurses do initial reviews based on Interqual or MCG guidelines and if the inpatients do not meet the criteria, they reach out to physician advisors to determine the status based on clinical presentation of the patient. Patients do not have to meet the criteria if physician can support longer stay requirement based on medical facts-severity of illness and intensity of treatment.

You do not have to remember all the interquel or MCG guidelines. With time, you can learn what the guidelines say about the most common conditions that we see in the hospital.

You can also talk to and learn from the utilization management nurses who do this daily, even after you start working. As a physician, all that you focus is looking for compelling reasons for the patient to stay in the hospital for more than 2 midnights. This is straight forward for Medicare patients but for Medicare advantage plan [Commercial Insurance] patients, the Medical Directors ask for a compelling reason to stay through the third midnight too.

If we work for hospital, we can review denials from insurance companies daily and choose to do effective peer to peer reviews so we can overturn those denials.

Some hospitals allow you to work only remotely and some want you to work on site. Physician advisor role truly can be what you want it to be-remote or onsite and relaxed or challenging.

Wherever you join, they will have a training program or classes to prepare you to do this job well.

If you are interested in CDI, Clinical Documentation Improvement, you can get training at Enjoin or Claro. Both are great companies to look at for good CDI education. Hospitals may have to arrange large group education from these companies. They usually do not do training classes for individual doctors. You can also do a certification course on documentation improvement through AHIMA and it is called the CDIP or clinical documentation improvement practitioner certification.

Once you become a physician advisor or if you are already a leader in your organization for anything else, does not have to be doing UM, you can become certified physician advisor.

As communication skills are essential to working as an effective physician advisor, try to train yourself to be able to tell things to others in a way that you don’t sound that you are ordering them. Be polite. Get things done by requesting. For example, when I want a physician to change the “Observation” status to “Inpatient” status, I tell them “Please change the patient to ‘inpatient’. This is time sensitive so please do ASAP so that hospital gets paid the deserved amount for the hard work you are doing. Thanks for your help”.

Keep yourself cool all the time and become good at handling conflicts or difficult situations.

Always, keep in mind that a physician advisor’s job is very easy if all the physicians/attendings taking care of the patient mention in daily progress notes the compelling reason for the patient to stay inpatient for everyday the patient is in the hospital. So encourage every physician to document this. The documentation in the chart should be aimed at insurance companies to pay appropriately apart from helping other doctors to know the plan of treatment.

If you want to work for an insurance company, you should become good at denying an admission but if you work for a hospital, you should become good at finding clinical reasons to argue in favor of an inpatient status. At the end of the day, you have to do what is right for the patients.

You can go to the website NAIRO.org and email all the members who are UM companies.

You can follow Dr. Ronald Hirsch on LinkedIn to learn more too. He is a Leader in health care quality and management with particular focus on Inpatient and Outpatient care and Centers for Medicare and Medicaid Services (CMS) regulations. He teaches physician advisors.

Join Physician Advisors Facebook group if you are interested to know more about Utilization reviews and talk and learn from others physician advisors.

Conclusion: Becoming a physician advisor to do Utilization Management is not that difficult. One may not get opportunity right away. If you are interested, you should start working on a few things mentioned above and in due time, your opportunity will come. Speaking to those who are already doing this is an excellent way to know the work flow. Webinars are really helpful in this regard.