SABR-COMET published in Lancet

[Mandelin Rain]

I'm planning to be bright-eyed attending who is willing to p2p and throw insurance companies under the bus in a chart on a daily basis as necessary for treatments that I feel very strongly about.

How long I'll last at that level of enthusiasm before the medical insurance establishment beats it out of me will be determined.

Them wanting to deny IGRT on a palliative case is small beans to me in comparison to denying an entire course of life-prolonging treatment.

I've never done the "put peer-to-peer reviewer's name in chart" thing.

I think I'm going to start though; and I'd encourage it as a global practice. If another physician is determining what is "medically appropriate" for a patient that they never examined or met, they should carry some of the liability of what happens to that patient I'd think. If you deny enough lung IMRT at V20<37%, I'd think at some point you'd cause an excess pneumonitis fatality. And the treating doctor should be able to point at the person who "actually" determined the treatment technique.

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[evilbooyaa]

I've never done the "put peer-to-peer reviewer's name in chart" thing.

I think I'm going to start though; and I'd encourage it as a global practice. If another physician is determining what is "medically appropriate" for a patient that they never examined or met, they should carry some of the liability of what happens to that patient I'd think. If you deny enough lung IMRT at V20<37%, I'd think at some point you'd cause an excess pneumonitis fatality.

I have threatened it on a p2p exactly 3 times in cases that I felt very, very strongly about. Not denying of IGRT, not denying of IMRT for say pancreas cancer, but something similar to denying of SBRT for oligometastatic disease.

Those 3 times I was able to get approval. Not a strategy I hope to have to use often, but will as necessary as an attending. I've been fortunate enough to discuss with Radiation Oncologists near exclusively during p2ps, although I think my experience with Evicore directly has been quite minimal. Need to prepare for a culture-shock when I go out into practice.

You want to force me to do 3D instead of IMRT for node-negative definitive gyn that's not getting extended field? Fine - I'm not going to be happy about it, but I'll do it. You want to tell me I can't bill 3D and can only bill complex treatment for the bone met patient as you won't approve a DVH? Fine.

 

[Mandelin Rain]

I have threatened it on a p2p exactly 3 times in cases that I felt very, very strongly about. Not denying of IGRT, not denying of IMRT for say pancreas cancer, but something similar to denying of SBRT for oligometastatic disease.

Those 3 times I was able to get approval. Not a strategy I hope to have to use often, but will as necessary as an attending. I've been fortunate enough to discuss with Radiation Oncologists near exclusively during p2ps, although I think my experience with Evicore directly has been quite minimal. Need to prepare for a culture-shock when I go out into practice.

You want to force me to do 3D instead of IMRT for node-negative definitive gyn that's not getting extended field? Fine - I'm not going to be happy about it, but I'll do it. You want to tell me I can't bill 3D and can only bill complex treatment for the bone met patient as you won't approve a DVH? Fine.

I guess my point is more general.

This is a medical doctor rendering an opinion on the medical necessity of a medical procedure. It's not a curbside type thing. They have full access to the patient's information and are being paid to render said opinion accurately and in good faith. It's essentially a second opinion on the patient's care.

I think I'm just going to start documenting both approvals and denials with the physician's name and city, It really only makes sense when you think about it. I encourage everyone to do so.

 

[evilbooyaa]

Fair enough I suppose, but it will be off-putting to most p2p folks, if you open every p2p with "so you are aware this call will be recorded and your recommendations will be put into the patient's chart for review in the future".

I guess you could document every single denial, even if they refuse your daily KV pairs for that palliative spine case.

But what's the point of documenting an approval? To show that Evilcore isn't all bad? I don't really feel the need to document that.

I wish doing a p2p was a reimbursable code from an insurance company, then I'd be happy to document every single one.

 

[deleted774703]

Fair enough I suppose, but it will be off-putting to most p2p folks, if you open every p2p with "so you are aware this call will be recorded and your recommendations will be put into the patient's chart for review in the future".

I guess you could document every single denial, even if they refuse your daily KV pairs for that palliative spine case.

But what's the point of documenting an approval? To show that Evilcore isn't all bad? I don't really feel the need to document that.

I wish doing a p2p was a reimbursable code from an insurance company, then I'd be happy to document every single one.

Just document it always. never hurts you and can CYA

 

[evilbooyaa]

Just document it always. never hurts you and can CYA

Document any and every p2p on any patient, ever? How does documenting an approval CYA?

I get documenting denials in case the patient develops toxicity of the 3D treatment that you didn't feel was appropriate, but the part that "it doesn't hurt" is that it hurts me by making me do additional senseless, pointless documentation.

 

[deleted774703]

Document any and every p2p on any patient, ever? How does documenting an approval CYA?

I get documenting denials in case the patient develops toxicity of the 3D treatment that you didn't feel was appropriate, but the part that "it doesn't hurt" is that it hurts me by making me do additional senseless, pointless documentation.

I’m talking about the denials

 

[ramsesthenice]

I'm planning to be bright-eyed attending who is willing to p2p and throw insurance companies under the bus in a chart on a daily basis as necessary for treatments that I feel very strongly about.

How long I'll last at that level of enthusiasm before the medical insurance establishment beats it out of me will be determined.

Them wanting to deny IGRT on a palliative case is small beans to me in comparison to denying an entire course of life-prolonging treatment.

They won't tell you that you can't do it. They will tell you that they won't pay for it. If you firmly believe in it you can accept their reimbursement for 3D or (if you are lucky) IMRT/VMAT. If your chairman or partners are ok with you doing SBRT and not getting paid for it you won't have any issues. For most companies you simply won't win a P2P on this one. They have algorithms.

 

[scarbrtj]

They won't tell you that you can't do it. They will tell you that they won't pay for it. If you firmly believe in it you can accept their reimbursement for 3D or (if you are lucky) IMRT/VMAT. If your chairman or partners are ok with you doing SBRT and not getting paid for it you won't have any issues. For most companies you simply won't win a P2P on this one. They have algorithms.

you make a good point. However I think it's still good to document the disconnect between MD recommendation and insurance co recommendation. However, this would not be "CYA" legally. Malpractice cases require medical negligence 100% of the time. None of the "treatment recommendations" from Evicore are medically negligent.

 

[Burt Radnolds]

I'm planning to be bright-eyed attending who is willing to p2p and throw insurance companies under the bus in a chart on a daily basis as necessary for treatments that I feel very strongly about.

How long I'll last at that level of enthusiasm before the medical insurance establishment beats it out of me will be determined.

Them wanting to deny IGRT on a palliative case is small beans to me in comparison to denying an entire course of life-prolonging treatment.

I feel you evil but gator and and neuronix are on the mark. I have raged against the machine, but despite all my rage I am still just a rat in a cage.