My first assignments in case management were in the late 1980s; at first, it was mostly utilization management, but it evolved. At that time, we had a "medical director"; yet, he acted in similar roles as today's physician advisors (PAs; although a more limited role). The term "physician advisor" was introduced by companies that delivered off-campus advisory services to support hospital case/utilization management teams. Over the years, it grew into a full-time, in-house position, primarily in hospitals.

In the Evolution of the Physician Advisor, Quinn (2022) states that the PA was the "subject-matter expert employed to guide utilization management (UM) departments toward finding the most appropriate status determination for a hospital encounter. Whether in-house or from an outside agency, health systems sought PA expertise to reduce their audit risk, in addition to defending against denials. Value added by PAs was recognized as both regulatory and financial" (p. 1).

Over the years, the PA, who had become a regulatory and revenue integrity force with whom to be reckoned, has now become a clinical documentation integrity/improvement champion as well. Throughout the evolution of the PA-with the use of physician judgment and how to manage the regulatory changes/mandates, utilization of the PA resulted in improved reimbursements from overturned denials (Quinn, 2022).

The critical roles are many. The PA is not only a critical role on the interdisciplinary team, it is one that has regulatory components and, therefore, must be accessible. They must be a part of some of Medicare's regulations such as ensuring compliance with the Medicare Conditions of Participation, discharge appeals, and Condition Code 44 activities. There are several major advantages to having dedicated PAs. Typically (in addition to regulatory duties), these include the following (Powell & Tahan, 2019):

* Improved clinical documentation

* Assists in reducing avoidable delays/days

* When a denial occurs, PAs are a resource to help get them overturned. Payor medical directors may deny authorization with an option sometimes given for peer-to-peer discussion. A facility may escalate cases to PAs before, during, or after the authorization/denial process.

* Functions as a liaison and educator between case management and practice partners; this is not only about medical necessity but also about education on laws, rules, and regulations.

* Serves as a resource for case management in many ways! This partnership is key to our success.

This aligns closely with a conversation I recently had with a prominent PA: Ariana Peters, DO, FACOI, FHM, CMPC. I recently read that, in the final 2 months of 2022, the Centers for Medicare & Medicaid Services (CMS) released more than 5,000 pages of new regulations and the U.S. Congress passed into law a 4,000-plus page omnibus spending bill that had more than 1,000 pages of health care provisions. As many physician groups are still trying to dig through all of this paper to make sense of what these 2022 end-of-year laws and regulations will mean for them (Emper, 2023). I asked Dr. Peters two questions: here are her answers:

What are the pressing issues facing physician advisorsin 2023?

1. Denials-It is no secret that many health plans are denying care in an almost frivolous manner. Peer-to-peer consults often result in overturned denials. However, the amount of time and resources for these are enormous. In particular, in our region, and I suspect across the country, denials from Medicare Advantage Plans (MAPs) are increasing exponentially.

2. How to better engage with revenue cycle-In a large system, the smooth communication with revenue cycle is paramount, but not always easy. Time is well spent assuring care management and revenue cycle understand and smoothly work together.

3. How to teach providers and departments/divisions about denials and medical necessity documentation-clear documentation of the medical necessity and the plan of care must be documented to prevent denials. Especially in teaching facilities, the importance of teaching trainees good documentation habits to carry with them after residency cannot be overstated.

How can case managers support their physician advisors?

"In an effort to preemptively prevent denials of care, PAs depend on Case Managers to do all they can before engaging the PA. This includes calling the practice for clarification and to assure all the relevant documentation is completed. Case Managers need to be proactive about educating providers, and then follow up to make sure the providers make the requested documentation updates. If this is not completed, that is the time to engage the PA, who can assist with provider education.

I would also like the case managers to be confident in their reviews on a case. Be confident in your expertise and knowledge. Know that the PA values your opinion on a case and will take your recommendations into consideration when reviewing a case. We want to know what you think, as you are just as much the subject matter experts as the PA is."

In this Editorial, I have used the voice and experience of a seasoned PA. This aligns with another article in this issue of PCM Journal, "Can History Change Our Future Course? Lessons From Case Managers Across Time" by Moreo, Llewellyn, Sands, Luttrell, Prince, and Owen. In a profession where so many are started to "age out"-using the wisdom of those with experience is both critical and wise.

So, to all the PAs ... and to all case managers ... your work is invaluable and gaining prominence and even more visibility, now more than ever. It is the collective job of the case managers, the PAs, and revenue cycle to collaborate to reduce the inevitable challenges and barriers put forth within the health care system.

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