Payers are increasingly asking for peer-to-peer conversations. This requires the patient’s physician to take time out of his or her busy schedule to discuss the case with the payer physician.
“Peer-to-peers are happening much more than in the past,” says Ronald Hirsch, MD, FACP, a physician with Chicago-based R1 RCM Physician Advisory Solutions. The main reason behind the surge in peer-to-peers is that health plans are seeking to avoid paying a hospital bill for an inpatient admission. “If a peer-to-peer is needed, the next question is who should do it,” Hirsch explains.
If it is a question of the medical necessity for the procedure, the physician is best-suited to participate. “They are aware of the indications and other therapies that have been tried,” Hirsch observes.
Sometimes, the question is more about the patient’s status as an inpatient or outpatient. “Most practicing physicians have little understanding of the nuances of this,” Hirsch says.
Hospitals work with multiple payers, and each uses a different method to determine the patient’s status. “Expecting the physician to understand that is unreasonable. And that is where the hospital’s physician advisor should be utilized,” Hirsch offers.
Patient access is not conducting the peer-to-peer, but can facilitate these requests. To do so, says Hirsch, “patient access should have a close working relationship with the physician advisor.”
There is no guarantee the payer will overturn the denial, even after the peer-to-peer happens. Success rates for these calls varies widely. “Several variables affect the outcome,” Hirsch notes.
It all depends on how willing the payer’s physician is to listen. “Many insurance medical directors already have their mind made up before they take the call,” Hirsch says. “Nothing will convince them to change it.”
Other payer physicians are willing to hear the hospital’s viewpoint. Some conclude the initial decision to deny the claim was made with limited information. “Once the physician, or physician advisor, fills in the gaps, the claim gets approved for payment,” Hirsch says.
In 2015, Ensemble Health Partners revamped its processes in response to a surge of payer requests for peer-to-peers. Physician advisory, virtual utilization review, and bedded insurance authorization teams were created. These groups are responsible for:
- reviewing level of care/patient status for appropriateness;
- identifying if medical necessity guidelines are met;
- following up on medical necessity denials and peer-to-peer requests.
Payers are not making it easy. Already-short timeframes from payers to complete the peer-to-peers are shrinking, says Kathy White, AVP of virtual utilization review and bedded insurance authorization.
Busy attending physicians have no time for the lengthy phone calls. “Some payer contracts require the attending to perform the peer-to-peer,” White notes. These specify that the physician advisor is not allowed to do so.
For patient access, there are two main challenges: tracking that the peer-to-peer was completed, and tracking the outcome (whether the denial was upheld or overturned). This is a time-consuming process that diverts patient access staff from other tasks. “There is an administrative strain on staffing to complete the full process of scheduling, documenting, and determination,” White says.
Ideally, fewer peer-to-peers are requested. Patient access does its part by obtaining authorizations for scheduled cases. Thorough documentation in the medical record gives the payer no reason to ask for the peer-to-peer in the first place. “We track this at the physician level, looking at progress notes and quality documentation,” White says.