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Oh hi.
I’m AlmostAnMD. You may remember me from such topics as “POWERHOUSE RESIDENCY” and “Maybe Husel was just really good at palliative care?”
Today I’m here to talk to you about the exciting world of utilization management (UM). I said I’d do this after I left EM but wanted to wait a year for two reasons.
Now your first question is probably a fair one. “AlmostAnMD, if you’re burned out on EM, why not consider doing X instead?” Where X is:
-interventional pain
-EMS fellowship
- urgent care
-telemedicine
-sports medicine
-“administration fellowship”
-peds EM
-toxicology
-surgical critical care
-Newman Anesthesia certificate
-disaster medicine
-ultrasound fellowship
-“do another residency”
-anesthesia critical care
-Newman’s house of propofol
-“go into academics”
-palliative care
-neurocritical care
-undersea and hyperbaric medicine
-“does this smell like propofol to you?”
-addiction medicine
-“own a freestanding”
- ask wife to be more productive
-brain injury medicine
-concierge medicine
-kill self
-cruise ship medicine
-aesthetics certificate/med spa
-geriatrics fellowship
-global health fellowship
-involuntary Newman proceduralist
-Research fellowship
-medical education fellowship
--“work fewer shifts”
-population health fellowship
Those are all great questions, most of which are legal. But instead, I chose UM. But before I explain why I chose UM or explain what I actually DO as a physician advisor in the UM field, I’ll explain why I left EM. I think starting with that a good point because before starting something new you should consider if the old is working for you or not.
For me, it was not. I am one of those folks truly region-locked due to a spouse that I want to stay with and she is an ultra-specialist of her non-medical field. There are literally two places in the country we can be where she can work and every other place she’s effectively a housewife or working well outside of her PhD/bringing in less bank.
And already, you’ve probably found the first hurdle. If you’re the breadwinner taking a risk by leaving steady employment—especially if kids are involved, like my situation—this feels dangerous. Having a working spouse that makes decent money is a great support in case things go sideways. If your spouse doesn’t work, tell him/her to get their ass back to work, because it’s the 21st century and tradwife on your own goddam time because it’s time for your ass to get comfy.
And if you don’t have a spouse or kids then you’ve got nothing to lose anyway, your risks are your own, just run with your gut and GTFO and do whatever makes you happy.
As far as EM goes, I fell into a crappy situation. I was a decent resident/chief. They started showing metrics my third year of residency (to the chagrin of most) and I was like a standard deviation above every other person in my class for pph, which as an attending is a pointless thing to brag about but as a resident it made me feel badass.
I guess what I’m trying to say is I felt generally prepared to be an attending by the time I finished residency. Like any good resident, I sold shifts to junior residents to moonlight and made real money while still in residency. I cannot emphasize the personal and financial value of moonlighting enough. I distinctly remember my first rural, critical access shift. I called @Tenk because I thought I just killed a guy with chest pain because I sent him home.
I mean, he had some benign BS story, mid 40s, days of pain and I held him for two trops. Looking back, wonder why I didn’t do 3 or 4 just to make it last the whole shift. Obviously someone like that now half the time I might not even order labwork depending on how busy I am but whatever. The point is, moonlighting is great for making bank, learning productivity and checking your fear at the door.
I’d say this skill carried well into my attending job. But after a year or so I realized I joined an ASS SDG and it ran the entire city I was in. So I essentially had no choice but to keep working there since the alternative was a one way 90 minute drive. If you’re single that’s great, if you’ve got family/kids, less so. So I basically just made it work.
I won’t try to make this about my EM work, but as a general rule, any of the following is probably a flag when it comes to determining malignancy. In no particular order:
I mean honestly this list could be 30 points longer, and I’ve dove into them in separate topics, but it’s really not the point. The main takeaway is it felt like EM wasn’t going to work out. Couldn’t really change groups, couldn’t realistically drive forever and leaving town ruins spouse career.
In 2023, two things happened.
The first was an event at a shift. I saw doc that was late-age—like, should have retired years ago, but I dunno has multiple divorces or something—completely lose his ****. Went nuts on something relatively minor, like a lab error or nurse not doing something. But he was throwing ****, screaming, cursing, even when it was done just muttering under his breath.
I dunno why but for some reason, I looked at him and thought holy ****, that’s going to be me if I don’t get out of here. I mean sure my stocks could take off, we could win the lottery, etc…but at some point you have to actually take control of your destiny, so I made the mental commitment that night to get out.
The second thing was actually a post on here! Someone made a post about doing utilization work, which I didn’t even know existed or what it was, and I exchanged a few PMs about it with him. So I decided that would be my exit.
But, going into it blind without any connection or experience is a steep ask. So I started here:
Peer Review Services
You basically just need a license. They give you some cases to review and they’ll give you some criteria to match it against to approve or deny stuff. (NOTE: this is not at all what I do now! But it’s a CV builder).
For hospital-based stuff, they use MCG. MCG is a “national guideline” (lol, IYKYK) that they ask you to see if specific cases meet specific criteria. This requires no MD or brains at all. In fact, in my current job it’s being replaced with AI and/or UM RNs that manually do these reviews. I have a familiarity now with InterQual and MCG but most med necessity reviews are more holistic than that, so I only use them to check certain things to see what the denial chances are.
The case review stuff sucked. Hard. It paid ass, they wanted fast turnaround times, and the learning curve is a bit steep so if they only offer 80 bucks for a review and it takes you two hours to do it, you start to wonder if it’s worth it.
Long term, probably not. I mean, definitely not. But it’s not a long term thing. I did it for better part of a year to pad my CV as someone with experience in medical necessity, as well as someone with at least a passing understanding of MCG. Looking back, that’s a decent way to do it. The other way, or way to add to your CV, is to get certified here:
Home
Getting your ACPA-C is mandatory for most docs working in utilization, at least physician advisor jobs, which I have.
It’s like a 700 buck test and takes 3 days to go through the modules. It’s a decent course as well, teaches you the basics of 2 midnight rule, DRG vs per diem payors, etc. Prepares you for higher level things than the BS I was doing. Also they have an annual conference where I think they just hand out jobs? So get certified and go to that if desired. They also do the course/certificate live at the conference as well, but then you miss most of the conference.
So a year of experience goes by and I’m just applying for jobs like a mad man. I learned from a guy that also burned out of EM about what kind of jobs to look for. Avoid these:
Home
This, and many like it. If it’s all you can get, do it for a few years to build experience and leave. Just as TH/USUCKS only cares about grinding your meet, these are the UM equivalents. You have no autonomy, no one cares about you, and you’re just handed caseloads to maximize your revenue potential. It’s a remote-work version of EM work, really. Also the pay is ass, the guy told me he made $150,000/yr doing this. Do not do this.
Instead, do what I did.
The “sweet spot” of UM jobs is actually working FT for hospitals/hospital systems. You should start by asking your own utilization department if they are hiring internally. If you work in a hospital or hospital system that has 300+ beds, you definitely, and for sure, have a utilization department. Otherwise your hospital is hemorrhaging so much money it can’t even stay afloat, trust me. This gets into the weeds of UM a bit, but insurance has stepped up their denials game considerably over the last decade and without UM the hospital will shut down. If you’re at a smaller/more “backwards” shop/system, UM will fall under case management.
Just ask their director if they’re hiring for advisor jobs. The case review stuff I mentioned is great for a CV booster, but I know most systems will train their own docs do be advisors, understanding that it’s not something people get exposure to in residency/attendinghood.
In my case, my system has physician advisors. I met with their director, who told me they didn’t have openings or expect them anytime soon. A double-edged sword, really…does your ED have an attending spot open? Of course it does, people are leaving left and right. Turnover is a marker for job satisfaction, and that’s why the ED turnover at my old group was like a revolving door. It’s probably also why the hospital system I left hasn’t hired an advisor in 5 years, for the opposite reason.
But this field is exploding in most places, so systems that are realizing they are losing money to insurance are hiring like crazy:
These are all system/non-profit gigs. They pay more, work you less and just care about getting job done than worrying about if you’re actually turning cases every 2 seconds. Hell I have some days I get some decent gym work in, but that’s between printing cold cash and meetings.
This is literally how I found my current job. Saw a nonprofit system level job, took my meager CV to the interviews and knocked it out every level of interview.
Gonna divide the last section up between what being a physician advisor actually is and what I, specifically, do. Since I’m diverging considerably from the normal PA route.
First, the thing you probably care about most—pay. Honesty, I can’t tell you much here for two reasons. Firstly, “salary data” is what I got from google. Per google, the average physician advisor makes 204k/yr. But it also says “top earners” make over 280K and I’m considerably north of that, on the bellcurve at top 99% of advisors. So my experience could be unique, my boss might not understand I’m overpaid, or the salary data I saw is grossly outdated or doesn’t factor in part-timers (there are a LOT of part-time advisors, FT is more rare, understandably, as people are reticent to actually hang up their stethoscope).
I’m FT. 40 hours a week, M-F, 8a-4p, full remote. No weekend or night work. Anything that happens outside those hours will get handled during next business day.
Also I get a month of paid vacation a year, which is sweet, compared to my old SDG that just “scheduled around” your vacation request. IE, if you work 18 shifts/month, a two week vacation to Europe requires you to work those shifts around your vacation. As you can guess, even bridging between months, that’s just not an ideal situation. So I ****ing love my vacation time. Another life change is paternity leave
Child A—born while working at SDG—schedule around induction date, hope she doesn’t go early because of the calloff headache, get 4 shifts off in a row for hospital then go back to work
Child B—3 weeks paid paternity leave. I didn’t even bring it up, actually. I told my boss the wife was pregnant and immediately he was like, “YOU NEED TO FILE FOR YOUR PATERNITY LEAVE!” So, cool. Absence can actually be supported.
Which entices YOU more? Lol
Other than that, the bennies are pretty much the same bells/whistles of medical/vision/dental/401K etc. So enough about bennies, the next part of this writeup is a breakdown of the actual work itself.
At a smaller system/single hospital you might do all 3, but at a larger system (mine) you will generally do one of three tracks: patient flow, CDI, denials.
CDI is clinical documentation integrity. Honestly this isn’t my track, but I have minimal training in the area and can generally describe it. This involves coding denials or clinical validity denials—ie, was the patient truly septic? If not, expect a downgrade. Was the data just not captured well? Then expect a downgrade. Data not being captured well can cause the same thing, but advisors can step in and argue these charts to preserve the original coding. There’s also a lot of system-level work these people related to charting templates to minimize clickbox hell but also maximize billing. This work is done by people that also understand clicking isn’t fun, but it’s a part of medicine.
Again, I can’t tell you a WHOLE lot about CDI since it’s not the “track” I went with.
Next is patient flow. I fill this roll occasionally for the system when the usual suspects can’t.
Responsibilities
Literal patient flow
Why isn’t someone discharging? Not the usual social work BS, but medical issues delaying care, teams that are just sitting on patients for days and not doing anything, etc.
Other hospital committee stuff as needed
UM committee work, other committee work, I don’t know much about these because I don’t do these either. But this is where larger policy/system changes can take place.
That’s an oversimplification of CDI/flow, because I don’t do much of these, honestly.
My forte is denials.
I mostly love denials because it gives me a chance to see how healthcare actually works. I know a lot about medicine, but healthcare and medicine could not be less related. To be good at inpatient authorization denials you really should know federal and states laws well, so it turns you into a policy dork.
Of course, medical directors I talk to on peer-to-peers don’t know or care about laws, as I’ve found, so I get to work “with” the system to help overhaul things at the state level to prevent fraud and abuse from payors. This involves extensive projects related to reducing the denials work we do.
One person that we consulted with said denials are like stormtroopers. Working on denials, you can overturn them, but there’s always more stormtroopers. Always. The real trick is to go after the sithlords that send the stormtroopers. So that’s about 50% of my work now, being a jedi to go after sithlords.
So, this is where I divorce a bit from the usual PA denials role. I still do routine peer-to-peer medical necessity denials, but I’ve gone pretty far with the policy stuff, so specific that if I mention the work I largely out myself here but I’ll just say this work does what I wasn’t able to do in the ED: make a difference.
I’ve been able to literally reduce denials from even coming in by directly confronting insurance C-suite leaders with the laws they are breaking. A smaller single hospital probably can’t do that but we’re such a revenue stream we can actually make these threats (backed by lawyers, eternally nervous of litigation if I misspeak). Ultimately, I’m just holding the payors to the law, which requires a lot of familiarity with the law. So if you like details or projects this is a fun route to go.
Myself, I burned out in the ED. Bad. Clock-in-clock out is a mentality that is absolutely valid, but I decided I want my life to actually mean something in a bigger picture. I’m finding I can have lasting impacts working with regulatory agencies to curb fraudulent claim denials—not just individual claims, but making impacts that change how claims are processed/reducing denials/decreasing payor fraud. At the end of the day, it’s deeply rewarding work.
The thing I miss most about ED work is the time off and the pay. But with a recent promotion (this gets a little too specific for public posting, PM for details if you really care but honestly it’s not worth really going into detail anyway) I’m essentially paid the same as the full-time ED doc I was, so that’s essentially nullified.
The time off though isn’t even that big a deal either. ED work is….WORK. At least mine was, I was drowning at times. This work is more like doing 15 hours of “intense” work over 40 hours. Like I said, time to take wife out to lunch, do some kid stuff, get some exercise, etc….it’s not 40 hours of constant ass-in-chair.
I think the other element worth mentioning here is respect. I’ve mentioned this in detail in other topics, but it’s worth repeating again—you are nobody in the ED. Literally a replaceable husk of a human wearing a stethoscope, easily swapped out by someone else.
I’ve developed an ultra-specialized knowledge base (I’m a voracious reader) and I have a high capacity for legal review/policy work. So that’s allowed me to serve as an expert consultant across this multi-state system on key cases or be the “go-to” guy for a lot of specific nuances.
The difference between how I’m treated now vs as an ED doc is night-and-day. To be fair, and I’ve said this before, I didn’t go into medicine so people could sniff my farts and feel joy, but constantly being blamed/dumped on/people throwing semen at me (happened a few times)/consultants yelling at me weren’t worth 400k/yr. No thanks. I guess you can call me a diva for that but not being reminded I’m a worthless **** constantly just got to me after a while.
It actually took a loooong time coordinating denials overturned for specialists to realize the script flipped dramatically. Solid organ transplant docs are incredibly humble when they find out you’re the guy that can get things auth’d, etc. They can’t flex their badass skills if they aren’t allowed to use them!
The work-life balance is an infinite improvement. I’m rarely up past 10p now. I love to make dinner with the kids, training them to be little chefs. I’m home for dinner every day since my work doesn’t leave lol. If I need to call off for any reason it’s not a big deal, we schedule light enough that cross-coverage isn’t stressful to fill another role. I have every weekend free forever.
No malpractice insurance since I can’t (easily) kill anyone. So, fear of lawsuits is gone. My notations I leave are in a separate part of epic not discoverable, too. If you’ve wondered why you don’t see EPIC notes from advisors, that’s because ours are hidden and visible only to UM RNs. My understanding is this is fairly universal with robust programs.
As far as the future of the field goes, it has a role for AI but for now I see that only increasing efficiency. As long as payors are going to try to break the law—forever—an AI program isn’t likely to replace us. I used to hate committee work/meetings, but in a more productive environment that’s honestly just how you get things done/make changes. If a payor is breaking a law/doing a type of denial, you can complain about it, or gather the right people, schedule a meeting, talk to the lawyers, file the appeals, the CMS complaints, etc…make a difference. Stop it from happening.
Finally, I’ll close with the professional organizations. One of my biggest “jading factors” was ACEP. What a criminal cartel of a waste of dollars. It’s a snake that starts at ED docs at the head and ends with CMGs at the tail. The only thing they care about is reimbursement because that’s the CMG priority. Not safe staffing ratios. Not protecting ED docs. Not residency expansion. The motive of ACEP is clear, and anyone giving any dollars to them for any reason is equally guilty for the decline of this specialty. At least try AAEM, that was my professional org until I left EM. AAEM is the crazy uncle that we won’t realize was right all along with the conspiracy theories until it was too late.
ACPA has an amazing conference, NPAC. Yeah there’s the usual boozefest but the actual meeting is built to find ways for systems to fight denials. This year there were some amazing talks that transformed how we operate as a system. With all that I’ve learned, excited to see next year’s work. A lot of these talks are from people that are just trying various ways to annoy insurers into following the rules, or discovering obscure rules to make stuff work.
I honestly can’t remember a single ACEP talk I ever went to. It was mostly garbage/self-aggrandizing circle jerks. I remember half the talks I saw earlier this year since so many directly impacted what we are doing in an evolving field.
I’m refusing to proof-read any of this because it’s too long. It’s possible cat walked across keyboard at some point, sorry. Open to specific questions for the one or two people with enough attention span to read.
I’m AlmostAnMD. You may remember me from such topics as “POWERHOUSE RESIDENCY” and “Maybe Husel was just really good at palliative care?”
Today I’m here to talk to you about the exciting world of utilization management (UM). I said I’d do this after I left EM but wanted to wait a year for two reasons.
- Posting about UM with only a month or two of experience isn’t helpful to anyone
- If I make it a year, that makes it sound like I could actually make it two…or three…or just be done with EM entirely (current plan).
Now your first question is probably a fair one. “AlmostAnMD, if you’re burned out on EM, why not consider doing X instead?” Where X is:
-interventional pain
-EMS fellowship
- urgent care
-telemedicine
-sports medicine
-“administration fellowship”
-peds EM
-toxicology
-surgical critical care
-Newman Anesthesia certificate
-disaster medicine
-ultrasound fellowship
-“do another residency”
-anesthesia critical care
-Newman’s house of propofol
-“go into academics”
-palliative care
-neurocritical care
-undersea and hyperbaric medicine
-“does this smell like propofol to you?”
-addiction medicine
-“own a freestanding”
- ask wife to be more productive
-brain injury medicine
-concierge medicine
-kill self
-cruise ship medicine
-aesthetics certificate/med spa
-geriatrics fellowship
-global health fellowship
-involuntary Newman proceduralist
-Research fellowship
-medical education fellowship
--“work fewer shifts”
-population health fellowship
Those are all great questions, most of which are legal. But instead, I chose UM. But before I explain why I chose UM or explain what I actually DO as a physician advisor in the UM field, I’ll explain why I left EM. I think starting with that a good point because before starting something new you should consider if the old is working for you or not.
For me, it was not. I am one of those folks truly region-locked due to a spouse that I want to stay with and she is an ultra-specialist of her non-medical field. There are literally two places in the country we can be where she can work and every other place she’s effectively a housewife or working well outside of her PhD/bringing in less bank.
And already, you’ve probably found the first hurdle. If you’re the breadwinner taking a risk by leaving steady employment—especially if kids are involved, like my situation—this feels dangerous. Having a working spouse that makes decent money is a great support in case things go sideways. If your spouse doesn’t work, tell him/her to get their ass back to work, because it’s the 21st century and tradwife on your own goddam time because it’s time for your ass to get comfy.
And if you don’t have a spouse or kids then you’ve got nothing to lose anyway, your risks are your own, just run with your gut and GTFO and do whatever makes you happy.
As far as EM goes, I fell into a crappy situation. I was a decent resident/chief. They started showing metrics my third year of residency (to the chagrin of most) and I was like a standard deviation above every other person in my class for pph, which as an attending is a pointless thing to brag about but as a resident it made me feel badass.
I guess what I’m trying to say is I felt generally prepared to be an attending by the time I finished residency. Like any good resident, I sold shifts to junior residents to moonlight and made real money while still in residency. I cannot emphasize the personal and financial value of moonlighting enough. I distinctly remember my first rural, critical access shift. I called @Tenk because I thought I just killed a guy with chest pain because I sent him home.
I mean, he had some benign BS story, mid 40s, days of pain and I held him for two trops. Looking back, wonder why I didn’t do 3 or 4 just to make it last the whole shift. Obviously someone like that now half the time I might not even order labwork depending on how busy I am but whatever. The point is, moonlighting is great for making bank, learning productivity and checking your fear at the door.
I’d say this skill carried well into my attending job. But after a year or so I realized I joined an ASS SDG and it ran the entire city I was in. So I essentially had no choice but to keep working there since the alternative was a one way 90 minute drive. If you’re single that’s great, if you’ve got family/kids, less so. So I basically just made it work.
I won’t try to make this about my EM work, but as a general rule, any of the following is probably a flag when it comes to determining malignancy. In no particular order:
- A medical director has been medical director longer than I’ve literally been alive (no exaggeration or joke)
- No vertical movement in the years I was there—no room for advancement/rotation of leadership roles
- Secret bonuses for medical directors. I don’t know what they were, but our peasant bonus felt weirdly low for seeing insane acuities and patient volumes
- Weird trend where staffing is fantastic for medical directors but suddenly midlevel/doc coverage drops when directors aren’t working (and pointing this out is apparently not good teamwork)
- Leadership does not work nights, regardless of age
- Docs mysteriously disappear off schedule. Frequently. And sometimes never come back. This also includes people that have been here a decade+. Then rumors fly, and none of them are good
I mean honestly this list could be 30 points longer, and I’ve dove into them in separate topics, but it’s really not the point. The main takeaway is it felt like EM wasn’t going to work out. Couldn’t really change groups, couldn’t realistically drive forever and leaving town ruins spouse career.
In 2023, two things happened.
The first was an event at a shift. I saw doc that was late-age—like, should have retired years ago, but I dunno has multiple divorces or something—completely lose his ****. Went nuts on something relatively minor, like a lab error or nurse not doing something. But he was throwing ****, screaming, cursing, even when it was done just muttering under his breath.
I dunno why but for some reason, I looked at him and thought holy ****, that’s going to be me if I don’t get out of here. I mean sure my stocks could take off, we could win the lottery, etc…but at some point you have to actually take control of your destiny, so I made the mental commitment that night to get out.
The second thing was actually a post on here! Someone made a post about doing utilization work, which I didn’t even know existed or what it was, and I exchanged a few PMs about it with him. So I decided that would be my exit.
But, going into it blind without any connection or experience is a steep ask. So I started here:
Peer Review Services
You basically just need a license. They give you some cases to review and they’ll give you some criteria to match it against to approve or deny stuff. (NOTE: this is not at all what I do now! But it’s a CV builder).
For hospital-based stuff, they use MCG. MCG is a “national guideline” (lol, IYKYK) that they ask you to see if specific cases meet specific criteria. This requires no MD or brains at all. In fact, in my current job it’s being replaced with AI and/or UM RNs that manually do these reviews. I have a familiarity now with InterQual and MCG but most med necessity reviews are more holistic than that, so I only use them to check certain things to see what the denial chances are.
The case review stuff sucked. Hard. It paid ass, they wanted fast turnaround times, and the learning curve is a bit steep so if they only offer 80 bucks for a review and it takes you two hours to do it, you start to wonder if it’s worth it.
Long term, probably not. I mean, definitely not. But it’s not a long term thing. I did it for better part of a year to pad my CV as someone with experience in medical necessity, as well as someone with at least a passing understanding of MCG. Looking back, that’s a decent way to do it. The other way, or way to add to your CV, is to get certified here:
Home
Getting your ACPA-C is mandatory for most docs working in utilization, at least physician advisor jobs, which I have.
It’s like a 700 buck test and takes 3 days to go through the modules. It’s a decent course as well, teaches you the basics of 2 midnight rule, DRG vs per diem payors, etc. Prepares you for higher level things than the BS I was doing. Also they have an annual conference where I think they just hand out jobs? So get certified and go to that if desired. They also do the course/certificate live at the conference as well, but then you miss most of the conference.
So a year of experience goes by and I’m just applying for jobs like a mad man. I learned from a guy that also burned out of EM about what kind of jobs to look for. Avoid these:
Home
This, and many like it. If it’s all you can get, do it for a few years to build experience and leave. Just as TH/USUCKS only cares about grinding your meet, these are the UM equivalents. You have no autonomy, no one cares about you, and you’re just handed caseloads to maximize your revenue potential. It’s a remote-work version of EM work, really. Also the pay is ass, the guy told me he made $150,000/yr doing this. Do not do this.
Instead, do what I did.
The “sweet spot” of UM jobs is actually working FT for hospitals/hospital systems. You should start by asking your own utilization department if they are hiring internally. If you work in a hospital or hospital system that has 300+ beds, you definitely, and for sure, have a utilization department. Otherwise your hospital is hemorrhaging so much money it can’t even stay afloat, trust me. This gets into the weeds of UM a bit, but insurance has stepped up their denials game considerably over the last decade and without UM the hospital will shut down. If you’re at a smaller/more “backwards” shop/system, UM will fall under case management.
Just ask their director if they’re hiring for advisor jobs. The case review stuff I mentioned is great for a CV booster, but I know most systems will train their own docs do be advisors, understanding that it’s not something people get exposure to in residency/attendinghood.
In my case, my system has physician advisors. I met with their director, who told me they didn’t have openings or expect them anytime soon. A double-edged sword, really…does your ED have an attending spot open? Of course it does, people are leaving left and right. Turnover is a marker for job satisfaction, and that’s why the ED turnover at my old group was like a revolving door. It’s probably also why the hospital system I left hasn’t hired an advisor in 5 years, for the opposite reason.
But this field is exploding in most places, so systems that are realizing they are losing money to insurance are hiring like crazy:
These are all system/non-profit gigs. They pay more, work you less and just care about getting job done than worrying about if you’re actually turning cases every 2 seconds. Hell I have some days I get some decent gym work in, but that’s between printing cold cash and meetings.
This is literally how I found my current job. Saw a nonprofit system level job, took my meager CV to the interviews and knocked it out every level of interview.
Gonna divide the last section up between what being a physician advisor actually is and what I, specifically, do. Since I’m diverging considerably from the normal PA route.
First, the thing you probably care about most—pay. Honesty, I can’t tell you much here for two reasons. Firstly, “salary data” is what I got from google. Per google, the average physician advisor makes 204k/yr. But it also says “top earners” make over 280K and I’m considerably north of that, on the bellcurve at top 99% of advisors. So my experience could be unique, my boss might not understand I’m overpaid, or the salary data I saw is grossly outdated or doesn’t factor in part-timers (there are a LOT of part-time advisors, FT is more rare, understandably, as people are reticent to actually hang up their stethoscope).
I’m FT. 40 hours a week, M-F, 8a-4p, full remote. No weekend or night work. Anything that happens outside those hours will get handled during next business day.
Also I get a month of paid vacation a year, which is sweet, compared to my old SDG that just “scheduled around” your vacation request. IE, if you work 18 shifts/month, a two week vacation to Europe requires you to work those shifts around your vacation. As you can guess, even bridging between months, that’s just not an ideal situation. So I ****ing love my vacation time. Another life change is paternity leave
Child A—born while working at SDG—schedule around induction date, hope she doesn’t go early because of the calloff headache, get 4 shifts off in a row for hospital then go back to work
Child B—3 weeks paid paternity leave. I didn’t even bring it up, actually. I told my boss the wife was pregnant and immediately he was like, “YOU NEED TO FILE FOR YOUR PATERNITY LEAVE!” So, cool. Absence can actually be supported.
Which entices YOU more? Lol
Other than that, the bennies are pretty much the same bells/whistles of medical/vision/dental/401K etc. So enough about bennies, the next part of this writeup is a breakdown of the actual work itself.
At a smaller system/single hospital you might do all 3, but at a larger system (mine) you will generally do one of three tracks: patient flow, CDI, denials.
CDI is clinical documentation integrity. Honestly this isn’t my track, but I have minimal training in the area and can generally describe it. This involves coding denials or clinical validity denials—ie, was the patient truly septic? If not, expect a downgrade. Was the data just not captured well? Then expect a downgrade. Data not being captured well can cause the same thing, but advisors can step in and argue these charts to preserve the original coding. There’s also a lot of system-level work these people related to charting templates to minimize clickbox hell but also maximize billing. This work is done by people that also understand clicking isn’t fun, but it’s a part of medicine.
Again, I can’t tell you a WHOLE lot about CDI since it’s not the “track” I went with.
Next is patient flow. I fill this roll occasionally for the system when the usual suspects can’t.
Responsibilities
- ED management. Ever wonder why beds are held, some patients go upstairs first, some patients stay for discharge? Or what about patients just transferring out rather than getting admitted?
- If you don’t have an efficient system that doesn’t happen, or nurses run it, which is worse. Basically I’ll divert patients away from tertiary facilities that just need community resources (lobar PNA, COPD tx, etc) to keep flagships open for business for specialty care. It sometimes flows in reverse when flagships are weirdly more open than communities. The goal is just to maximize bed availability of all hospitals and increase throughput, not favoritism or site/specialty requests.
- Status management of the ED
Literal patient flow
Why isn’t someone discharging? Not the usual social work BS, but medical issues delaying care, teams that are just sitting on patients for days and not doing anything, etc.
Other hospital committee stuff as needed
UM committee work, other committee work, I don’t know much about these because I don’t do these either. But this is where larger policy/system changes can take place.
That’s an oversimplification of CDI/flow, because I don’t do much of these, honestly.
My forte is denials.
I mostly love denials because it gives me a chance to see how healthcare actually works. I know a lot about medicine, but healthcare and medicine could not be less related. To be good at inpatient authorization denials you really should know federal and states laws well, so it turns you into a policy dork.
Of course, medical directors I talk to on peer-to-peers don’t know or care about laws, as I’ve found, so I get to work “with” the system to help overhaul things at the state level to prevent fraud and abuse from payors. This involves extensive projects related to reducing the denials work we do.
One person that we consulted with said denials are like stormtroopers. Working on denials, you can overturn them, but there’s always more stormtroopers. Always. The real trick is to go after the sithlords that send the stormtroopers. So that’s about 50% of my work now, being a jedi to go after sithlords.
So, this is where I divorce a bit from the usual PA denials role. I still do routine peer-to-peer medical necessity denials, but I’ve gone pretty far with the policy stuff, so specific that if I mention the work I largely out myself here but I’ll just say this work does what I wasn’t able to do in the ED: make a difference.
I’ve been able to literally reduce denials from even coming in by directly confronting insurance C-suite leaders with the laws they are breaking. A smaller single hospital probably can’t do that but we’re such a revenue stream we can actually make these threats (backed by lawyers, eternally nervous of litigation if I misspeak). Ultimately, I’m just holding the payors to the law, which requires a lot of familiarity with the law. So if you like details or projects this is a fun route to go.
Myself, I burned out in the ED. Bad. Clock-in-clock out is a mentality that is absolutely valid, but I decided I want my life to actually mean something in a bigger picture. I’m finding I can have lasting impacts working with regulatory agencies to curb fraudulent claim denials—not just individual claims, but making impacts that change how claims are processed/reducing denials/decreasing payor fraud. At the end of the day, it’s deeply rewarding work.
The thing I miss most about ED work is the time off and the pay. But with a recent promotion (this gets a little too specific for public posting, PM for details if you really care but honestly it’s not worth really going into detail anyway) I’m essentially paid the same as the full-time ED doc I was, so that’s essentially nullified.
The time off though isn’t even that big a deal either. ED work is….WORK. At least mine was, I was drowning at times. This work is more like doing 15 hours of “intense” work over 40 hours. Like I said, time to take wife out to lunch, do some kid stuff, get some exercise, etc….it’s not 40 hours of constant ass-in-chair.
I think the other element worth mentioning here is respect. I’ve mentioned this in detail in other topics, but it’s worth repeating again—you are nobody in the ED. Literally a replaceable husk of a human wearing a stethoscope, easily swapped out by someone else.
I’ve developed an ultra-specialized knowledge base (I’m a voracious reader) and I have a high capacity for legal review/policy work. So that’s allowed me to serve as an expert consultant across this multi-state system on key cases or be the “go-to” guy for a lot of specific nuances.
The difference between how I’m treated now vs as an ED doc is night-and-day. To be fair, and I’ve said this before, I didn’t go into medicine so people could sniff my farts and feel joy, but constantly being blamed/dumped on/people throwing semen at me (happened a few times)/consultants yelling at me weren’t worth 400k/yr. No thanks. I guess you can call me a diva for that but not being reminded I’m a worthless **** constantly just got to me after a while.
It actually took a loooong time coordinating denials overturned for specialists to realize the script flipped dramatically. Solid organ transplant docs are incredibly humble when they find out you’re the guy that can get things auth’d, etc. They can’t flex their badass skills if they aren’t allowed to use them!
The work-life balance is an infinite improvement. I’m rarely up past 10p now. I love to make dinner with the kids, training them to be little chefs. I’m home for dinner every day since my work doesn’t leave lol. If I need to call off for any reason it’s not a big deal, we schedule light enough that cross-coverage isn’t stressful to fill another role. I have every weekend free forever.
No malpractice insurance since I can’t (easily) kill anyone. So, fear of lawsuits is gone. My notations I leave are in a separate part of epic not discoverable, too. If you’ve wondered why you don’t see EPIC notes from advisors, that’s because ours are hidden and visible only to UM RNs. My understanding is this is fairly universal with robust programs.
As far as the future of the field goes, it has a role for AI but for now I see that only increasing efficiency. As long as payors are going to try to break the law—forever—an AI program isn’t likely to replace us. I used to hate committee work/meetings, but in a more productive environment that’s honestly just how you get things done/make changes. If a payor is breaking a law/doing a type of denial, you can complain about it, or gather the right people, schedule a meeting, talk to the lawyers, file the appeals, the CMS complaints, etc…make a difference. Stop it from happening.
Finally, I’ll close with the professional organizations. One of my biggest “jading factors” was ACEP. What a criminal cartel of a waste of dollars. It’s a snake that starts at ED docs at the head and ends with CMGs at the tail. The only thing they care about is reimbursement because that’s the CMG priority. Not safe staffing ratios. Not protecting ED docs. Not residency expansion. The motive of ACEP is clear, and anyone giving any dollars to them for any reason is equally guilty for the decline of this specialty. At least try AAEM, that was my professional org until I left EM. AAEM is the crazy uncle that we won’t realize was right all along with the conspiracy theories until it was too late.
ACPA has an amazing conference, NPAC. Yeah there’s the usual boozefest but the actual meeting is built to find ways for systems to fight denials. This year there were some amazing talks that transformed how we operate as a system. With all that I’ve learned, excited to see next year’s work. A lot of these talks are from people that are just trying various ways to annoy insurers into following the rules, or discovering obscure rules to make stuff work.
I honestly can’t remember a single ACEP talk I ever went to. It was mostly garbage/self-aggrandizing circle jerks. I remember half the talks I saw earlier this year since so many directly impacted what we are doing in an evolving field.
I’m refusing to proof-read any of this because it’s too long. It’s possible cat walked across keyboard at some point, sorry. Open to specific questions for the one or two people with enough attention span to read.
