As you know I have a Facebook group for Physician advisors where physician advisors ask questions. Here are some most commonly used questions repeatedly. I thought if I collect and put all of them together, it will save a lot of time for many.
- Do you need to be licensed in all the states to work as physician advisor remotely or if one state license will work ? Only one license needed for Medicare and Tricare as these are federal programs. It depends on the employer and the state for commercial payers and Medicaid. It’s better to ask the employer for clarification.
- Is it possible to work for UM from out of the country? It is not possible to work for UM from outside the country at this time.
- Should I stay out of clinical medicine altogether after I join full time UM? If possible, it’s better to keep clinical privileges’ active just in case. However, there are a lot of physicians who gave up clinical medicine completely. Positions generally require board certification by ABMS.
- Do I need to buy E&O insurance? Usually, your employer provides you with E&O insurance which is the standard practice. No need of full medical malpractice insurance.
- Are you allowed to work from anywhere in US or do you have to stay in home state? You need to check with your employer on this one. Some companies do not have tax domicile in some states and also you should look at how the taxes work living in one state vs the other in relation to the state in which the employer is located in. But, usually, companies have physician advisors working remotely from several states.
- How much clinical work experience is recommended before pursuing physician advisor work? At least 3-5 yrs of clinical work is required to be able to enter UM filed to work as a physician advisor.
- Can Insurance Medical Directors deny an inpatient stay based on IQ or MCG criteria? Using IQ or MCG to deny IP stay is not allowed. Judgement should be based on Two midnight expectation.
- Is CHCQM or any other certification required to work as a physician advisor in UM? No, it is not required. Some places may prefer those with the certification but it is not publicized.
- What is the start time for calculating the 2 Mid Night bench mark? The starting point for the two midnight timeframe for medical review purposes will be when the beneficiary starts receiving services following arrival at the hospital by a medical personal. CMS notes that this instruction excludes wait times prior to the initiation of care, and therefore triaging activities (such as vital signs before the initiation of medically necessary services responsive to the beneficiary’s clinical presentation) must be excluded. A beneficiary sitting in the ED waiting room at midnight while awaiting the start of treatment would not be considered to have passed the first midnight, but a beneficiary receiving services in the ED at midnight would meet the first midnight of the benchmark.
- Do I need to be board certified to do utilization management work as physician advisor? Almost all jobs need a physician to be board certified in one of the specialties like Internal Medicine, Family Medicine, Pediatrics, Emergency Medicine etc.