Humana Medicare Announces Peer-To-Peer Process Changes

Once a denial is issued, a P2P will no longer be an option.

An astute physician advisor recently brought to my attention a change to the Humana Medicare Advantage peer-to-peer (P2P) process. The announcement (which can be found at this link: states that effective Aug. 1, a P2P with the “treating healthcare provider” will be requested prior to the plan issuing a medical necessity denial. Once a denial is issued, even if the patient is still hospitalized, a P2P will no longer be an option. At that point, the hospital will be forced to pursue a formal written appeal. Interestingly enough, this change does not apply to the Humana commercial or Medicaid Advantage processes.

Before getting riled up about this, it’s important to reach out to your health system’s contracting team to see what your current contract says. If there is no restriction about which physicians can participate in the P2P, then you can continue to utilize your physician advisors, if you currently do. But beware if the contract states your hospital is obligated to follow policy. If this is the case, you might be stuck with the change.

Looking into this more, I asked members of the community at large if they had any experience with P2Ps before a denial, or payors that only allow treating physicians to participate. Some reported timeline games that frankly sound diabolical. Imagine receiving a call at 3 p.m. notifying you that hospital days or inpatient status is not approved, and that a P2P must be scheduled by the end of the business day, just two hours later? And then, that the P2P must be scheduled by noon the following day or a denial will be issued? This for sure is something you should talk to your contracting office about to confirm it’s a process to which you are beholden.

Another strategy is to track such activity over time and see if you discover any potentially concerning trends that could be brought to your contracting specialists to address. Does an egregious timeline situation escalate toward the end of a quarter? Toward the end of each month? Is the health plan’s medical director actually prepared to discuss specifics of the case during the P2P? Or is he or she simply working from notes sent by an registered nurse (RN) case manager? If you feel you are being flooded with unreasonable denials/P2P requests, these particulars might help you to fight back.

Dr. R. Philip Baker, medical director of case management at Self Regional Healthcare in South Carolina and member of the Board of Directors for the American College of Physician Advisors, shared that the Centers for Medicare & Medicaid Services (CMS) informed several Medicare Advantage plans that once a denial is issued, the case must transition to a formal appeal and P2P is no longer an option. In some instances, this leads payers to require P2Ps to be scheduled within 24 hours of notification, but that doesn’t necessarily mean they will be scheduled so expediently.

“They can take as long as they like to return your call,” he said. “This is a technicality as to whether they call it a denial or pending denial, but the result should be the same as far as having the opportunity to (have) the discussion.”

Comparisons between treating physicians and physician advisors (or other utilization management physicians) regarding their performance in P2Ps have been made here on RACmonitor before. Often, there are lamentations about how treating physicians are either ill-equipped or uninterested in successfully defending patient status, for obvious reasons.

Treating physicians should be doing just that – treating patients. It’s understandable that attending physicians wish to complete the conversation quickly and move on to caring for their next patient. Dr. Tim Brundage, Certified Clinical Documentation Specialist and medical director for The Brundage Group, suggests preparing treating physicians for P2Ps by providing them a one-page “coaching synopsis” of the patient’s medical necessity to support inpatient status. Also, efforts can be made to include the physician advisor on the call to serve as a real-time support to the attending physician.

Unfortunately, as Day Egusquiza, president of AR Systems, Inc. often says, “where one payor goes…others follow.” So don’t be surprised if other private and managed plans proceed to follow Humana Medicare’s suit in the months to come.


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Juliet B. Ugarte Hopkins, MD, CHCQM

Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADV, is a physician advisor for case management, utilization, and clinical documentation at ProHealth Care, Inc. in Wisconsin. Dr. Ugarte Hopkins practiced as a pediatric hospitalist for a decade. She was also medical director of pediatric hospital medicine and vice chair of pediatrics in Northern Illinois before transitioning into her current role. She is the first physician board member for the Wisconsin chapter of the American Case Management Association (ACMA), a member of the RACmonitor editorial board, and a member of the board of directors for the American College of Physician Advisors (ACPA). Dr. Ugarte Hopkins also makes frequent appearances on Monitor Mondays and contributes to ICD10monitor.

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