Make ‘Peer-to-Peer’ Happen Within 24 Hours, Or Face Denied Claim
Patient access up against impossibly tight time frames
January 1, 2018
Payers are requiring timeframes as short as 24 hours for peer-to-peers between the patient’s and payer’s physicians, or they’ll deny the claim. Several strategies can make this conversation happen quickly enough to avoid denials.
- Have a mid-level provider contact the insurance company instead of physicians.
- Send physicians emails marked urgent to let them know the payers’ timeframe.
- Create a new position specifically for peer-to-peers.
“Peer-to-peers” — conversations between the patient’s doctor and the insurance company’s doctor — used to be infrequent at Tampa, FL-based Moffitt Cancer Center. Now these conversations are commonplace.
“This is happening even when complete clinical information has been sent,” says Viviana Mahon, manager of the financial clearance unit. (See story on reasons payers request peer-to-peers.)
Payers used to allow nurses to give clinical information to get services approved. “Nowadays, only mid-levels or higher can discuss cases with insurance companies,” says Mahon. “Payers do not want to discuss the clinicals with a nurse. They refuse to do so.”
In addition, payers are setting impossibly tight time frames for peer-to-peers. “Recently, insurance companies are closing peer-to-peer cases within 24 hours from the time it was escalated to their medical director,” says Mahon.
This is happening regardless of how long before service the request was submitted. Sometimes, it was done 15 days prior.
Physicians take time out of their busy schedule to speak directly with the payer’s physician, but are put on hold. “Many times, our physicians cannot wait 30 minutes on hold, so the case is closed,” says Mahon.
Even if the physician does connect with the payer’s physician, they often realize that the payer already has all the relevant information on the case.
“They find out, with surprise and frustration, that the information they are providing is nothing different from what the clerical team has already sent,” says Mahon.
Physicians are not always available to do the peer-to-peer on short notice. This causes denials. Patient access then needs to re-open the case and argue for payment. “This creates double work for everyone,” says Mahon.
Payers Are Disputing Patients’ Medical Needs
The patient access department at Tampa, FL-based Moffitt Cancer Center is seeing payers requesting peer-to-peers for these reasons:
- The payer is disputing the patient’s level of care.
Often, payers will approve observation status only. Evidence-based industry standards are used to justify the patient’s need for inpatient status. “However, some of the payers have their own internal policies as to what would meet the requirements,” says Parker.
For patient access, the challenge is to make sure of these two things:
– that pre-certification has been done for scheduled procedures;
– that inpatient dates are approved before scheduled procedures are completed.
“Provider education on documentation is key,” says Parker.
- The payer is objecting to the fact that the patient was in observation status for less than 24 hours.
Payers require an immediate peer-to-peer, or they will deny the inpatient status. This is happening even though the patient meets the criteria for inpatient level of care.
“What we hear frequently is that the patient does need inpatient status, but that the patient has to fail observation first in order to meet the criteria for inpatient status,” says Parker.
- The payer is disputing the need for ICU-level care as opposed to medical/surgical care.
“There is a trend of downgrading the level of care, which has financial implications,” says Parker.
Physicians Freed Up
At Moffitt Cancer Center, a new revenue cycle medical director position was created to do the peer-to-peers with payers. The position requires a physician assistant or advanced registered nurse practitioner degree. (See job summary and required qualifications.)
Revenue Cycle Role Handles Peer-to-Peers
The revenue cycle medical director is a newly created role at Moffitt Cancer Center in Tampa, FL. Below is the job summary and qualifications for this position:
- Assists medical staff and Patient Access RN in all aspects of the Peer-to-Peer Review Program, financial clearance, and medical necessity check.
- Communicates with clinical counterparts at the payer and within the cancer center.
- Organizes and prioritizes encounters needing financial clearance due to pending peer-to-peer reviews.
- This position is responsible for peer-to-peer conversations during the review process, as well as providing feedback to providers on upheld denials.
- Works directly with payers (insurance companies) using clinical expertise to obtain authorizations when the Patient Access RN team has been unsuccessful.
- Reduces/minimizes the need to escalate cases to Moffitt physicians to conduct a peer-to-peer discussion with the payer.
- Performs clinical review of medical records to determine if documentation is sufficient.
- Contacts payer directly or reaches out to ordering physician and/or clinical team to obtain additional information for the case prior to contacting payer to overturn the denial.
- Maintains a deep knowledge of payer classifications, rules, and criteria for authorizations and peer-to-peer process.
- Educates and advises providers, Patient Access RN, Financial Clearance Unit Manager and Supervisors.
- The individual in this position may work from a home-based office up to 24 hours per week, after a period of full-time onsite orientation at Moffitt.
- Required: Bachelor’s Degree
- Preferred: Master’s Degree
- Field of Study: Physicians’ Assistant or Advanced Registered Nurse Practitioner (ARNP)
Note: MD degree would also qualify, but is not required or preferred.
- Required: ARNP or PA
- Preferred; Oncology certification (OCN)
Minimum Experience Required:
- Minimum of five years’ ARNP/PA experience;
- One or more years’ experience in oncology;
- Strong computer skills, including use of electronic health records and hospital registration and billing systems;
- Knowledge of CMS regulations; third-party reimbursement processes, policies, and regulations; charging and coding guidelines;
- Strong communication skills and ability to provide succinct and clear clinical assessment verbally and in writing.
- Oncology experience in multiple disciplines, including administration of chemotherapy or radiation therapy and surgery. Experience with the treatment of a broad range of different cancers, including breast, lung, melanoma, leukemia, lymphoma, colorectal, stomach, liver, pancreas, neuroendocrine tumors, head and neck, endocrine, prostate, kidney, bladder, endometrial, cervical, ovarian, endocrine, brain tumors, etc.
SOURCE: Moffitt Cancer Center, Tampa, FL
Mahon used the fact that payers require a mid-level provider or higher to discuss cases to justify the new position. She was able to reclassify a nursing supervisor position as a revenue cycle medical director.
These steps are taken if a peer-to-peer review is requested:
- Nurses in the financial clearance unit gather clinical information to support medical necessity. “If the nursing team cannot find additional information in the patient’s record, then the ordering physician is contacted,” says Mahon.
- The revenue cycle clinical director contacts the payer to do the peer-to-peer. This frees up physicians from making the time-consuming calls. “It also decreased the number of denials and cases closed for physicians not contacting the insurance during the assigned times,” reports Mahon.
Pressure on Providers
Time frames for peer-to-peers are putting pressure on providers at Children’s Mercy Kansas City (MO).
“Frequently, we are seeing time frames of 24 to 48 hours, which is really difficult for providers participating in direct patient care,” says Sydney Parker, RN, BSN, ACM-RN, manager of utilization review.
The team warns physicians about payer time frames in emails marked urgent. Even if they call right away, there’s one more obstacle. “Actually getting through to who you need to talk to at the insurance company is another challenge,” says Parker.
Physicians sometimes leave messages that are not returned. “Some payers won’t take a pager number. Others call twice within an hour, then deny the claim because the physician wasn’t reached within the time frame,” says Parker.
Other times, payers simply don’t return the calls. “If the payer is behind on peer-to-peers, you may not hear from them for two weeks,” says Parker.
If the provider doesn’t get a call back, patient access contacts the payer. Even so, once the time frame has expired, the claim gets denied. Documentation of efforts made to schedule the peer-to-peers is helpful in this case.
“Fortunately, when you do a written appeal letter, it’s reviewed by a different medical director than the one who initially denied it,” says Parker. “Still, this is not always successful.”
To address the surge in peer-to-peer requests, Moffitt Cancer Center’s patient access department made these other changes:
- The department created a process for Advance Beneficiary Notice of Non-coverage/Financial Responsibility Acknowledgement.
This process is used if the payer denies an authorization after peer-to-peer review, or if Medicare does not consider a test medically necessary. If patients still want to proceed with the test, they’re asked to sign a financial responsibility form and pay a 25% deposit prior to service. If the patient doesn’t agree to this, the test is not performed. “The only exceptions are Medicaid patients,” says Mahon.
- Patient access asked physicians and the scheduling team for more time to obtain the authorization.
Previously, financial clearance didn’t have enough time to obtain authorizations between the date orders were placed and the date of service. This was especially difficult if a peer-to-peer had to be done.
“We asked for at least five business days for high-tech radiology,” says Mahon. “Our team works 21 days out, and 90% of the appointments 14 days out are financially cleared.” Fewer patients are rescheduled.
To garner support for the change, patient access educated physicians on the importance of having ordered tests approved by the payer in advance. “Otherwise, the charges are written off, affecting our capacity to have resources to help more patients,” explains Mahon.
Prep Physicians for Call
Payers are re-writing the rule book in terms of how peer-to-peers are handled. Recently, a payer attempted to contact a pulmonologist at the Children’s Mercy NICU directly to discuss a plan of care.
“Payers don’t always go through the proper channels,” says Parker. “They are finding other avenues to get to physicians, who are being taken away from the bedside.”
Ideally, the team discusses the case with the payer’s reviewer. This way, the physician can be given a heads-up on exactly what the payer is seeking.
“Sometimes payers are looking for opportunities for a lower level of care or discharge,” says Parker. Physicians blindsided by unexpected calls might inadvertently give the payer a reason to deny the authorization.
“We have implemented some strategies to get our physicians prepared for these conversations,” says Parker. Here are two ways physicians can push back against denials:
- Physicians can refer to evidence-based guidelines.
“We also supply our physician with the rationale of the utilization review nurse,” says Parker.
The physician can then use this information, along with specific clinical guidelines, to argue that services should be authorized. For instance, the physician may state that according to pediatric asthma guidelines, a patient with a history of persistent difficult breathing, mental status changes, and who is receiving high-flow oxygen with frequent monitoring meets criteria for ICU-level care.
- Physicians can inform payers that some services are unavailable in rural areas.
“For instance, if a home ventilator patient requires private duty nursing and it is not available, inpatient care must continue to be provided — and covered — until services required for discharge to home are available,” says Parker.
- Viviana Mahon, Manager Financial Clearance Unit, Moffitt Cancer Center, Tampa, FL. Phone: (813) 745-1937. Email: [email protected].
- Sydney Parker, RN, BSN, ACM-RN, Manager, Utilization Review, Children’s Mercy Kansas City (MO). Phone: (816) 701-5264. Email: [email protected].
Payers are requiring time frames as short as 24 hours for peer-to-peers between the patient’s and payer’s physicians, or they’ll deny the claim. This article discusses several strategies that can make this conversation happen quickly enough to avoid denials.
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