EXECUTIVE SUMMARY
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:
- Anticipate the need for certain pieces of clinical documentation;
- Ask patients to contact payers directly;
- Make it easy for physicians to participate in peer-to-peer requests.
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:
- When insufficient clinical information is provided, and payers want more supporting documentation to prove medical necessity;
- For claims involving transfers to and from facilities;
- When higher acuity level of care is requested;
- When the patient is readmitted to the hospital.
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:
- When unlisted codes are used.
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.
- When payment is requested for treatments or services that were recently approved by the FDA.
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.
- When the patient’s primary diagnosis conflicts somewhat with the treatment requested.
“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.
SOURCES
- Jackie Jordan, MBA, CHAM, Patient Access/Scheduling Manager, Kadlec Regional Medical Center, Richland, WA. Phone: (509) 942-2797. Email: [email protected].
- Brandon McCord, Director, Pre-Service Center, Ochsner Health System, New Orleans. Phone: (504) 842-9329. Email: [email protected].
These requests require the patient’s physician to consult with the payer’s physician before a claim is approved.
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