Peer-to-Peer Review Pitfalls & Solutions

A Peer-to-Peer Review is a conversation between two healthcare professionals, usually licensed doctors, over the phone discussing a patient’s case. The Peer-to-Peer Review (P2P) process is used to explain or clarify something the clinical record cannot convey clearly. The core of a P2P call basically focuses on matching medical necessity criteria with reimbursement criteria.

Who Initiates a Peer-to-Peer Review?

Insurance company reviewers and primary care providers may initiate P2P calls based on their employer guidelines. Providers ask to speak with insurer as part of a prior authorization requirement asking for approval for care, like length of stay, prescriptions, level of care, and other options. Prior authorization upsets everyone in healthcare for various reasons, and ranks as one of the most divisive issues in the industry.

An adverse determination/denial also sparks requests from providers wanting to understand the decision or add more insight into a case with the hopes of reversing the decision. Policy, facility, and insurer guidelines determine if, when, and how these requests occur.

Insurers, usually the reviewer or Medical Director, request P2P calls before determinations because they want additional information or details from the primary care doctor.

A Bad Reputation

The concerns about reimbursements and the tedious phone tag process make these conversations uncomfortable and time-consuming, contributing to their negative reputation. Imagine trying to find 15-30 minutes open time in two hectic schedules through voicemails and support staff. No wonder some insurer and provider-based doctors are unenthusiastic about making the calls.

Peel back the procedural and money baggage from the process and these are conversations between two doctors determining care.

Ways to Improve the Process

Removing the administrative logistics from the call process improves the Peer-to-Peer Review headache significantly for the call participants. If the two doctors focus on prepping case information and answering the phone at the scheduled time, then much of the process angst goes away.

• Recording the calls and engaging a trained host monitor transcribing notes let’s doctors forget about capturing conversation and hyper-focus, becoming very efficient. Everyone’s time is maximized.
• Making the time for reviewing case histories and documentation definitely saves time on the call, especially if the doctors know a call will happen at a specific time. Prepping before each potential connection wastes time and adds additional onus on callers.

If insurers and providers think of the process of P2P call administration as second or third level burdensome task, then consider engaging outside vendors with systems and software creating the highest level of efficiencies, tracking, and documentation. Let the doctors focus on care and policies without the admin headaches weighing them down.

Provider relationships will improve when the doctors want to take the calls, instead of putting off the Peer-to-Peer conversations.