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Much can be gained when using peer-to-peer for denial mitigation.

Claim denials are at an all-time high.

A significant proportion of these denials begin with a concurrent review by the payer, leading to a concurrent denial. For any denials, getting them overturned is paramount. That goal is even more critical with a concurrent denial, as getting one of them overturned avoids the additional cost of appealing the payor’s decision. Performing a peer-to-peer call is the most common mechanism of overturning a concurrent denial.

Before the advent of the physician advisor (PA), peer-to-peers were conducted by frontline physicians, such as the treating hospitalists. Those same frontline doctors did not (and do not) like performing  peer-to-peers because:

  • They’re busy
  • The call usually comes at an inconvenient time
  • The attending physician doesn’t understand the “rules” the payer is using
  • The attending feels like his/her care and judgment are being questioned
  • Most importantly, the attending has likely spent little to no time preparing for the call

Experience suggests that peer-to-peer overturn rates are lower for frontline physicians, as compared to experienced PAs. Why is that? Because:

  • The effective conducting of a peer-to-peer call is a learned skill
  • Physician advisors understand and can use the “rules” that payors use, the “magic words,” so to speak, to get a denial overturned
  • PAs have a certain distance from the care that allows them to have a more collegial discussion (“hard on the problem and soft on the people”), leading to a more robust and hopefully successful outcome
  • Physician advisors have less time pressure when performing a peer-to-peer
  • Most importantly, PAs can fully prepare for a peer-to-peer call. 

Unfortunately, some payers insist that they will only speak with a physician caring for the patient. This is despite no clear regulation or legal rationale for such a policy. Given what we know about the common outcomes of a frontline physician’s peer-to-peers (see above), how should hospitals and PAs respond to that challenge? Physician advisors can work with frontline physicians to help them become more successful.

Specifically, PAs can:

  • Do the prep work for the frontline doctor, including composing a summary of the stay with key elements to support inpatient status (a “script,” if you like)
  • Identify some of the “magic words” (i.e., phrases from evidence-based criteria sets such as MCG or Interqual) to use during the call
  • Identify other key elements to point out, such as a prolonged observation stay (“this necessary hospital level care extended beyond a reasonable period of observation prior to the opportunity for a safe discharge”)
  • Coach frontline doctors on how to conduct a peer-to-peer (if they are willing).

Additional key coaching points can include:

  • Read the denial letter, and if the case has been prepped, read the case preparation carefully
  • Always have the case prep with you (assuming it has been printed out), as the call can come at any time
  • If possible, have the electronic medical record (EMR) open to the appropriate patient. Not infrequently, the medical director didn’t have the entire record available at the time of the denial. That dramatic “turn for the worse” on hospital Day 3 may be just the ticket to getting an overturn
  • Be friendly and professional. If you don’t agree with the medical director’s opinion, don’t get frustrated. It’s better to “agree to disagree”
  • You will likely encounter the same medical director on future calls. Being pleasant and choosing your battles carefully will help you be effective in the long run
  • When a medical director is firm about his/her decision, remember that the peer-to-peer is just the first step in the denial process. The hospital has several opportunities to appeal the decision.

Finally, regardless of who does the peer-to-peer, it is vital that every hospital undertake the following:

  • Establish a set routine for managing concurrent denials (i.e., who receives the denial, who notifies the PA, who arranges the peer-to-peer, etc.)
  • Track peer-to-peers including overturn rates (I continue to be surprised at how many hospitals don’t know their peer-to-peer overturn rates)
  • Learn from the upholds. What case elements led to the overturn? What payor-specific obstacles are there?
  • Support the frontline doctors in any way you can. Let me repeat that: support your frontline docs for any effort they put in in getting concurrent denials overturned
  • Express appreciation in being a part of the process, no matter how small, as it demonstrates a shared effort to get fair payment for the excellent care we (hospital, hospital staff, and medical staff) provide.

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Chris Shearer, MD, MPH

Dr. Chris Shearer, MD, MPH, completed his undergraduate and medical school degrees at Northwestern University in the Honors Program in Medical Education. Dr. Shearer worked as a family medicine physician for over 15 years before moving into hospital and organization leadership roles, including Medical Director of Advisory Services for 2 years. He now serves as Sound Physicians Chief Medical Offer for their physician advisory programs.

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