Physician Advisors and Case Managers: Collaboration in Learning and Practice 

Mary McLaughlin Davis, DNP, ACNS-BC, NEA-BC, CCM
Sr. Member, ACPA Advisory Board,
Past President CMSA

Physician Advisors and Case Managers have a long history of collaboration to meet common goals. The American College of Physician Advisors (ACPA) and The Case Management Society of America (CMSA) have worked together as partners since 2017. During this time, we have attended and presented at each organization’s conferences, and participated in the shared work of both organizations. 

The pandemic slowed the momentum of the relationship, but in no way did it end it nor did our respective members cease participating in our respective virtual conferences.   

This year both conferences were live and the CMSA President, Melanie Prince attended the ACPA Conference. Drs. Ahmed Abuabdou, Ronald Hirsch, and Erica Remer represented ACPA and presented at the CMSA Conference.  

Drs. Hirsch and Remer discussed the importance of Clinical Documentation in supporting the medical necessity of hospitalization for patients. Case managers learned how best practice documentation mitigates avoidable days and denials. Physician Advisors and Case Managers agree the electronic medical record is the patient plan of care and care coordination is a subset of the plan.  

Dr. Remer defined the Grand Unified Theory of Documentation detailing how Clinical Documentation Integrity (CDI) is the foundation to support a hospital and the mission, vision, and values it promulgates. It creates the bridge between the care, treatment, and management of patients and the adherence to quality and compliance metrics. CDI justifies patient status, medical necessity for treatment, and communication between the internal consultants and treatment teams.   

Case studies are impactful for the learner and Dr. Remer used examples from her family to describe the value of using succinct clinical terminology to describe why a patient needs an inpatient level of care, and specifically, in her case, an inpatient rehabilitation level of care. She stressed that physicians must document accurately to justify the cost/value/benefit ratio of the level of care they are ordering for their patient. 

Dr. Hirsch described to the case manager audience the difference between the Centers for Medicare and Medicaid (CMS) definition of medical necessity and the commercial insurance’s definition.  Private payers will not approve a higher level of care if they feel the patient will have the same outcome in a lower level of care. This resonated with the hospital case managers in the audience. They have faced denials to move patients to an acute rehabilitation unit/hospital or an LTAC, and the explanation of why this occurs will help them refocus on the patient’s expected outcome rather than focusing on criteria. The ACPA physicians connected CMSA’s key standard, advocacy, to how documentation from all members of the interdisciplinary team supports a patient’s care, site and hospital status.    

Drs. Ahmed Abuabdou and Erica Remer joined CMSA case managers Amy Ehrich and myself on a panel titled; Supporting Patient-Centered Care with Interpersonal Collaboration: The Case Manager and Physician Advisor Relationship.  

The panelists discussed the role, function, and responsibilities in the case manager and physician advisor relationship. Dr. Abuabdou and I described the roles in hospitals and hospital systems and Amy discussed her relationship with the Medical Directors at a large national managed care organization. Dr Remer described how accurate clinical documentation supports every aspect of the physician advisors’ and the case managers’ service.  

All agreed that cohesion between the physician advisors and the case managers is essential to achieve excellence in status determination, CDI, quality and performance improvement, managing expedited and long-term denials, compliance at every level, high-level revenue cycle practices, and coordination of care.   

CMS is proposing health equity-focused measures for adoption in the Hospital Inpatient Quality Reporting Program. This entails a process to capture screening and identification of patient –level, health-related social needs, such as food and housing insecurity, transportation needs, utility difficulties and interpersonal safety, https://www.cms.gov/newsroom/press-releases/cms-proposes-policies-advance-health-equity-and-maternal-health-support-hospitals. The Physician Advisors informed the audience that case manager documentation of patients’ Social Determinants of Health is allowable under the CMS proposed rule and could affect hospital reimbursement. This is an excellent opportunity for hospital case managers to advocate for their patients and for their hospitals in detailing why discharges are delayed for a seemingly noncomplex DRG.  

Mary McLaughlin Davis is the Director of Care Management Cleveland Clinic Main Campus and Akron General