Engaging in a peer-to-peer review can be tedious, time-consuming, and frustrating for physicians. The process of chasing down information, going back and forth with the payer’s medical director, and justifying an order competes for precious time and energy that can be spent on patient care.
Many hospitals find it challenging to manage, complete, or even attempt peer-to-peer reviews effectively, only to deal with them again on the back end of denial. However, with the right strategies in place, physicians can effectively advocate for patients, successfully overturn denials, and even avoid them in the first place.
Understand the Different Types of Denials
Understanding how and why coverage is denied is fundamental to advocating for the patient and hospital. In many cases, if not most, denials can be avoided with greater awareness of the plan’s criteria and more timely, robust documentation.
Typically, the peer-to-peer conversation will center on four types of denials:
- Medical Necessity – if the information provided doesn’t sufficiently support inpatient status
- Timely Notification – if the notification to authorize treatment was not received within the required period
- Clinical Validation – an attempt to deny the validity of the principal or secondary diagnoses in order to downgrade the DRG and lower the hospital’s reimbursem*nt
- Post-Acute Denials – disputing the patient’s placement in a skilled nursing, long-term care, or inpatient rehabilitation facility, even though their condition warrants it at the time of discharge
Peer-to-peer reviews are inevitable. That’s why it’s essential to build a playbook of strategies and prepare physicians to engage in these critical conversations effectively.
Identify the Best Advocate to Engage in the Peer-To-Peer Conversation
At the outset, it’s important to identify the best person to engage in a peer-to-peer conversation with the payer’s medical director. There are pros and cons to making this decision.
The attending physician caring for the patient at the bedside can describe in first-hand detail the true level of the patient’s illness. Unfortunately, it can be difficult for a busy clinician to give the peer-to-peer conversation the time, attention, or patience needed.
A physician advisor who specializes in utilization review will be familiar with the specific health plan contract and criteria and often has more control over their schedule. While they can bring experience and acumen to the challenging dynamics of peer reviews, some payers insist that their medical director speak directly with the attending physician.
In either case, collaboration and the combined insights of the physician advisor and the attending physician are important. The attending physician should document and fully brief the physician advisor on what is happening at the patient’s bedside. Likewise, the advisor should build a strong case to support coverageby preparing themselves or coaching the attending physician in advance.
Five Strategies for Success
Follow these five strategies for crafting a constructive and productive approach to peer-to-peer conversations:
1. Prepare Thoroughly
Thorough preparation starts with creating a timeline. Fill in any gaps in documentation with key details that support inpatient status or other medically necessary measures. It’s also vital to schedule carefully. Carry your phone and notes with you, so you don’t miss the call and lose by default.
2. Build Rapport and Respect
Building a friendly rapport can be difficult when time is short and the stakes high. Begin the call with a brief, informal greeting to establish a non-combative dynamic and level of trust required for a respectful conversation.
3. Keep a Positive Perspective
Entering a peer-to-peer conversation can be daunting when you feel the medical director has their mind made up going into the call and “holds all the aces” for the outcome. Try to discern their agenda, remain respectful, and keep in mind that it’s not personal even when you lose a very solid case.
4. Maintain a Clinical Lens
Appeal to the reviewer’s medical professionalism, especially if they are denying coverage based on a narrow interpretation of the guidelines for a very ill patient with multi-system disease. Paint a picture of the clinicians and patient at the bedside. You might genuinely ask, “Given these circ*mstances, where else – or how else – could we have cared for this patient safely?”
5. Set Firm Boundaries
This is your opportunity to advocate for your patient – their member. A medical director may interrupt you or rush through important clinical details. Even in the face of gamesmanship, don’t be thrown off. Politely and respectfully remind them that the case merits a well-structured call with a complete review.
Remember to Track Your Overturn Data
Keeping track of your peer-to-peer review outcomes can help your hospital improve on many levels. Your overturn rate is just one metric, so track your wins, too, as they tie directly to the return on the investment in a skilled physician advisor supporting your clinical physicians. Keep an eye on recurring denials by the diagnosis, the health plan, and the guidelines they follow. You can then address the root causes through education, process improvement, and contract negotiation.
Your command of the science of medicine wrapped in the art of firm but respectful communication will produce better and better results over time.Even if a denial stands, you will feel a sense of satisfaction that you gave it your best shot. What you learn from each peer-to-peer conversation will improve your strategy and hone your skills for the next one.
