Peer to peer for MRIs

[FrustratedFamDoc]

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I have noticed a trend over the past couple months that has me suspicious.

I have had 3 lumbar MRIs and a few CT scans to R/O badness come up with a peer to peer requests before approval. Granted, this is not unusual, however for this carrier (BCBS), I typically NEVER have to go through this process. Also, these are the first requests for a P2P that I've received all year, and they have all come in the last few months of the year. Has anyone else noticed a similar trend?

Is there a mechanism where if a patient has already hit their out of pocket deductible that makes these studies more difficult to get approved since insurance companies will have to foot the whole negotiated bill? I have a strange feeling that if I were to order under exact circumstances come January, they would go through no problem...

 

[septoplasty]

I have noticed a trend over the past couple months that has me suspicious.

I have had 3 lumbar MRIs and a few CT scans to R/O badness come up with a peer to peer requests before approval. Granted, this is not unusual, however for this carrier (BCBS), I typically NEVER have to go through this process. Also, these are the first requests for a P2P that I've received all year, and they have all come in the last few months of the year. Has anyone else noticed a similar trend?

Is there a mechanism where if a patient has already hit their out of pocket deductible that makes these studies more difficult to get approved since insurance companies will have to foot the whole negotiated bill? I have a strange feeling that if I were to order under exact circumstances come January, they would go through no problem...

So I do some utilization work, I can't explain the exact reason with your case, but usually the reasons why they're getting triggered is lack of clarity on diagnosis or supporting statement. The denials are usually criteria based (for ex. if you order MRI before doing basic imaging or PT), once that gets denied, you can appeal, at which point your documentation (support statement) would need to address the criteria and why you need an exception. Unfortunately, the issue is we don't always get any/good documentation from the prescriber office so that's why the P2P calls. You'll notice usually that they'll lead to an approval, usually, once you let the doc know why you're ordering it.

Yes, it seems like a waste, but you'd be surprised by the kind of crap that people order that isn't needed. Most recently, someone had ordered a hip joint w/ contrast to look at structures OUTSIDE the joint. These are not only expensive, but have adverse reactions to them.

The other angle is, certain plans have certain limitations before "restrictions" are placed, and this is strictly financial that I know nothing about, technically illegal, but no way insurers are that profitable if they don't deny crap or make it hard for docs.

Ps. I don't work for insurance companies, I do appeals i.e. when the insurer has denied the cases even after appeals from physicians.

 

[Fatalis]

I have noticed a trend over the past couple months that has me suspicious.

I have had 3 lumbar MRIs and a few CT scans to R/O badness come up with a peer to peer requests before approval. Granted, this is not unusual, however for this carrier (BCBS), I typically NEVER have to go through this process. Also, these are the first requests for a P2P that I've received all year, and they have all come in the last few months of the year. Has anyone else noticed a similar trend?

Is there a mechanism where if a patient has already hit their out of pocket deductible that makes these studies more difficult to get approved since insurance companies will have to foot the whole negotiated bill? I have a strange feeling that if I were to order under exact circumstances come January, they would go through no problem...

Same thing has been happening to me.... so weird and it is getting annoying fast

 

[Hamhock]

send that **** to the ER!

HH

 

[hallowmann]

send that **** to the ER!

HH

It's sad but true. The patient may end up spending more time and probably money, it'll ultimately cost a lot more in healthcare dollars and be yet another non-emergent emergency, but that's ridiculous and companies need to know that's not OK. If the study is necessary and waiting until tomorrow will mean it's all out of pocket, then maybe that's what needs to happen. Ridiculous though.

 

[deleted87716]

It just results in more specialty referrals. The scans get done eventually, but at a higher cost to everyone.

 

[FrustratedFamDoc]

It all goes through eventually, but it is strange to me that the glut of these have only come on recently with nothing else being different besides time.

Example: past 2 or 3 lumbar MRIs needing prior physical therapy before being approved through BCBS. I've ordered at least 50 this year, none have been problematic until recently.

Example #2: I've NEVER had problems having to do a scan to r/o malignancy. Had a BCBS patient. Documented 45 lb weight loss in the last year, heavy smoker. Ordered contrast C/A/P. I had to add chest pain to the diagnosis before they would do chest. Seriously?

 

[TableMD]

I have never done a peer to peer where the person on the other end had read my note, and my note are good.

My favorite so far was the physician telling me that before I got an MRI for a blown ACL (female teen), that I needed to send to PT first. I asked how often that worked and she didnt have a good answer....

 

[deleted87716]

I have never done a peer to peer where the person on the other end had read my note, and my note are good.

Yep. After one so-called "peer" asked me to present the case, I told her to just call me back after she had read my notes. She was like, "Hold on...mmm-hmm...OK...alright, here's your approval number." 🙄

 

[septoplasty]

I have never done a peer to peer where the person on the other end had read my note, and my note are good.

My favorite so far was the physician telling me that before I got an MRI for a blown ACL (female teen), that I needed to send to PT first. I asked how often that worked and she didnt have a good answer....

They probably meant post-hab. Haha!

 

[Bacchus]

This probably has to do with the new CMS "?guidelines" regarding imaging. For several of our payor contracts we're getting asked for more documentation. I don't know the best way to explain it. I'm not a big advanced imaging guy so haven't had too much.

Change Healthcare Announces CareSelect Imaging Open Access

December 26, 2019 — Effective Jan.

www.itnonline.com

 

[TableMD]

Documentation is great, as long as its read and considered before requiring a peer to peer

 

[yeasports]

Documentation is great, as long as its read and considered before requiring a peer to peer

I could not agree more. I just do sports and I order a ton of imaging. Not sure why some get flagged maybe just random? On a peer to peer I have never talked to someone competent. One of recent ( hello this is Dr. Insurance for your peer to peer did you consider a trial of physical therapy? Dr. Yeasports no as that would be malpractice for a ocd lesion on an 8 yo. ...20 seconds of silence. Dr. Insurance um ok I have your auth code.) Every single one of my ptp have been approved though, just time consuming. I sometimes bill a 99358 to insurance based on time spent on the ptp as I go out of my way to document correctly to get approval and I usually tell the ptp dr. to read my note and let me know when done, this usually ends with wow that meets criteria let me get you the auth code. Surprisingly once a month I will have a pt come in for MRI review and upon looking at the chart I see they only had one visit with pcp, no xray, and a diagnosis of pain only; not sure how that got approved. Sorry about the poor grammar I am not on my phone I just have poor grammar.