The trusted source for
healthcare information and
Some patient access departments see a surge in requests for “peer-to-peer” reviews from payers before authorizations are obtained. Effective strategies to prevent “no auth” denials:
There’s a recent uptick in requests for “peer-to-peer” from payers, according to some patient access leaders. These require the patient’s physician to consult with the payer’s physician before a claim is approved. “We have noticed each year more peer reviews are requested,” says Jackie Jordan, MBA, CHAM, patient access and scheduling manager at Kadlec Regional Medical Center in Richland, WA.
At Health First in Rockledge, FL, Patient Access Service Manager Shawn Smith sees peer-to-peer requests crop up in these situations:
At Kadlec Regional Medical Center, peer-to-peers are requested routinely if there is a lack of clinical information regarding tried and failed conservative treatment, absence of X-rays or ultrasounds, absence of labs, or absence of why a suspected condition was ruled out. “Payers are looking for specific information regarding the length and number of visits of any therapy, treatments, or injections, as well as the results of X-rays, ultrasounds, and lab results,” Jordan adds.
At Ochsner Health System in New Orleans, peer-to-peers are requested in these particular cases:
Anytime a medication or procedure does not have an official Current Procedural Terminology (CPT) and an unlisted code is used, insurance companies closely scrutinize the supporting clinical documents.
Brandon McCord, director of the pre-service center, says, “If the utilization nurse on the payer side is unfamiliar with the requested service, it will usually go to the medical director.” If the payer’s medical director is not a specialist in that area, a peer-to-peer is requested.
Payers will identify the requested service as “experimental.” Physician notes citing published statements or guidelines can counter claims denials effectively, as can pharmaceutical companies or vendors. “These groups usually have good resources and reimbursement-related information,” McCord notes.
“We are seeing this when there is a complex case, or multiple physicians on the same case,” McCord observes. A patient might arrive for something oncology-related, but a pulmonary or cardiac diagnosis supports the treatment request. Usually, this triggers a peer-to-peer request.
“This is an opportunity to work with operational leadership in identifying the correct supporting diagnosis,” McCord says.