The Future of Physician Advisors: Is There a Role in Outpatient Prior Authorizations?Clarissa Barnes, MD, FACP While individual physician advisors may have different roles and tasks, the profession in general focuses on three main groups of work. Specifically, physician advisors work in clinical documentation integrity (CDI), utilization review (UR), and case management (CM). And, historically, those functions have largely been inpatient focused. As the profession has expanded, physician advisors have found themselves moving into other areas including outpatient CDI, often with an emphasis on documentation as it relates to Risk Adjustment Factor (RAF) scores. Recently, it has become increasingly clear that physician burnout/moral injury is a significant issue in healthcare exacerbated in the setting of the recent COVID public health crisis. After burnout rates hovering in the 44% range on the annual Medscape survey of American physicians, rates have climbed to 50% or even higher in some specialties in the 2022 report (Kane 2019, Kane 2022). Top on the list of self-identified causes is increasing administrative hassles in the practice of medicine with 64% of physicians identifying that as the top cause in the same Medscape report (Kane 2022). Included in that list of administrative burdens is the use of prior authorizations as an additional step to procuring testing, medications, and/or treatment for patients. Prior authorization reform has become a hot topic of late and the Centers for Medicare and Medicaid Services (CMS) recently released “CMS Interoperability and Prior Authorization Rule CMS-0057-F.” The crux of the burden for prior authorization is the high administrative burden in actually completing the prior authorization combined with the lack of clarify surrounding what the payer is looking for due to different criteria sets for different organizations. The physician wants the service, medication, etc. to be covered and the rationale for a rejection is often unclear. So, in short, it is an area of medicine with high administrative burden and regulatory complexity with often different rules for different payors that could be improved with better understanding of the rules and improved documentation. This sounds like an ideal target for physician advisors to me! This does not mean the involvement of physician advisors is the only solution to prior authorization issues. Prior authorization reform is still important as is enforcement of those rules. However, it is unlikely prior authorizations themselves will be removed as a payer tool since it is one of the few mechanisms that payers have to control utilization. Rather, physician advisors are well poised to join the fight and assist their clinical counterparts with their unique skillset in documentation, utilization management, and understanding of regulations. Dr Barnes is the South Dakota Medicaid Medical Director |