What Are PA Services?
Exactly what are PA services? Physician Advisors serve in multiple capacities throughout healthcare and managed care organizations. They conduct medical necessity reviews, may be called upon to assist in organizational audits, and in some cases are essential in identifying and reversing inappropriate medical necessity denials and a variety of appeal levels. Some of the responsibilities of a physician advisor, or peer reviewer, may include the following:
- Conduct Initial Reviews
- Standard reviews and Medical Necessity Reviews
- Expedited reviews
- Concurrent reviews
- Active Role in the Appeal process
- Clinical treatment shaping and consultation
- Utilization Management medical necessity reviews
More Detailed Information about the Scope of Work for Physician Advisors may be found below:
INITIAL REVIEW: Clinical review conducted by appropriate licensed or certified health professionals. Initial clinical review staff may approve requests for admissions, procedures, and services that meet clinical review criteria, but must refer requests that do not meet clinical review criteria to peer clinical review for certification or non-certification. Sometimes referred to as “first level review.”
STANDARD REVIEW OR APPEAL: A request to review a determination not to certify an admission, extension of stay, or other health care service conducted by a peer reviewer who was not involved in any previous non-certification pertaining top the same episode of care.
EXPEDITED APPEAL: A request by telephone for additional review of a determination not to certify imminent or ongoing services requiring a review conducted by a clinical peer who was not involved in the original decision not to certify.
CONCURRENT REVIEW: Utilization management conducted during a patient’s hospital stay or course of treatment sometimes called “continued stay review.”
UTILIZATION MANAGEMENT (UM): Evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the auspices of the applicable health benefit plan; sometimes called “utilization review.”
For more information on the Physician Advisor and Independent Review Organization services offered by BHM Healthcare Solutions, please visit our website: https://bhmpc.com. Please click on the gift box below to receive a free presentation on medical necessity criteria