What does a physician advisor do?
Short answer
A physician advisor is a physician who helps a hospital make and defend status and medical necessity decisions. They review cases flagged by case management, advise on inpatient vs. observation status, speak with payer medical directors in peer-to-peer reviews, support appeals and teach clinicians to document clearly. They connect clinical care, utilization review and revenue.
Last reviewed by board-certified physician advisors
Day-to-day work
- Secondary review: a second physician look at cases case management can't resolve with screening criteria
- Status advice: inpatient, observation or outpatient, based on Medicare and payer rules
- Peer-to-peer calls with payer medical directors on pending or issued denials
- Appeals: writing or reviewing the clinical argument in appeal letters
- Utilization review committee work, including Condition Code 44 status changes
- Education: teaching hospitalists and other physicians what documentation needs to show
In-house vs. external physician advisors
Larger hospitals and health systems often employ one or more physician advisors. Smaller and rural hospitals usually can't justify a full-time position, so they use an external physician advisor service, reached by phone, text or a secure platform.
Many hospitals combine the two: an in-house lead for committee work and education, with external advisors covering nights, weekends, overflow and peer-to-peer calls.
Signs a hospital needs one
- Rising denials, especially from Medicare Advantage plans
- A high observation rate or frequent status changes
- Peer-to-peer calls that go unanswered or are handled by busy attending physicians
- Denials that are written off instead of appealed
- Case managers with no physician to escalate to
Key terms
Common questions
Is a physician advisor the same as a case manager?
No. Case managers, usually nurses, screen cases and coordinate care and discharge. The physician advisor is the physician they escalate to for medical necessity and status decisions, and who speaks to payers physician-to-physician.
Does a physician advisor need a special certification?
There's no single required certification beyond an active medical license. Strong physician advisors usually have board certification in their specialty plus training and experience in utilization review, Medicare rules and appeals.
Can a physician advisor work remotely?
Yes. Most reviews, peer-to-peer calls and appeals are done by phone and through the medical record, so external physician advisors can cover hospitals anywhere in the US.
Talk with a physician advisor
Tell us about your hospital and we'll set up a call with one of our physician advisors.