peer to peer reviews

[AndyDufrane]

so I am doing a peer to peer for a commercial insurance today,got denied for acute inpatient rehab unit, its 80 something yo w/ AFib, CAD, gout,HTN, HLP, mechanical fall, hip fx s/p ORIF, previous I w/ ADLs, only used cane for mobility, married, lives w/ wife, tolerating therapy-min A w/ RW 10 ft but inhibited by pain, and family med physician med director is arguing about the patient not be to tolerate 3 hrs of therapy, and I even did a c/s on this guy, and the soulless family med insurance doc arguing w/ me that patient can't tolerate 3 hr therapy, and I tell him he needs close monitoring he has post op anemia, worsening renal function, serial INR for coumadin, and he just tells me to put in for it again tomorrow, is this some way for them to wear me down?

any input, how to effectively do these peer to peers, its very frustrating, so what seems to me a no brainer ARU admission

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[lobelsteve]

Peer to fp is not peer to peer. Tell him he is out of scope and demand for same specialty review.

 

[Louisville04]

Peer to fp is not peer to peer. Tell him he is out of scope and demand for same specialty review.

Wouldn't he argue due to all the comorbidities that it is within his scope?

 

[lobelsteve]

Wouldn't he argue due to all the comorbidities that it is within his scope?

Nope. Right to demand PMR to PMR. We are not asking if he needs acute medical, just acute inpatient rehab. FP probably does not know what PMR is.

 

[RUOkie]

the key to dealing with Insurance reviewers is to be a bit of a bully. Like Steve said, first demand to speak to someone who meets the criteria to be a Med Director for Inpt rehab hospital (which is usually PM&R). If they refuse, ask for the reviewer's license number in your state and ask him/her to spell the name clearly. When they ask why, tell them that you are wanting to document the denial clearly in the medical record so that if/when an untoward event happens, you are protected, and the liability gets shifted to the reviewing doctor for denial of care. Usually that alone will get you what you think the patient needs.

And ALWAYS be nice, never angry. Be matter of fact, and friendly about everything.

 

[lobelsteve]

the key to dealing with Insurance reviewers is to be a bit of a bully. Like Steve said, first demand to speak to someone who meets the criteria to be a Med Director for Inpt rehab hospital (which is usually PM&R). If they refuse, ask for the reviewer's license number in your state and ask him/her to spell the name clearly. When they ask why, tell them that you are wanting to document the denial clearly in the medical record so that if/when an untoward event happens, you are protected, and the liability gets shifted to the reviewing doctor for denial of care. Usually that alone will get you what you think the patient needs.

And ALWAYS be nice, never angry. Be matter of fact, and friendly about everything.

Idle threat. Those of us who do reviews understand that there is no doctor-patient relationship and no malpractice can occur. There is insurance carried by the review companies that covers the reviewer if there is negligence in omitting data or falsifying data in the review.

 

[drusso]

Just say you don't consider the reviewer experienced to render a proper opinion.

 

[AndyDufrane]

the trick that worked is that once I the patient was denied for acute inpatient rehab, I explained the situation to the wife, who took it upon herself to call the insurance company, and that seemed to do the trick , patient approved for acute inpatient rehab

 

[RUOkie]

Idle threat. Those of us who do reviews understand that there is no doctor-patient relationship and no malpractice can occur. There is insurance carried by the review companies that covers the reviewer if there is negligence in omitting data or falsifying data in the review.

I agree. I do insurance reviews. But when the reviewer does not meet the standard of expertise, he or she should defer to someone who has the expertise. As it stands, in the 18yrs I've been in practice, I've only had one thing I asked for be denied after a peer to peer. And that was because I couldn't make a good argument. It was borderline, and I was doing it for the hospital that I was med director for. I didn't push matters. But on the two occasions that I made that "Idle threat", the reviewers were not licensed in OK (where I live), which is a requirement for peer to peer reviews in my state. They would have been sanctioned by our state board.

 

[DMBandFan86]

I've recently started doing more peer-to-peers for IPR. I didn't really have much experience with it prior or in my training. I tried to review some forums on here but they seem pretty old.

Anyways, I pretty much understand the peer review process and sometimes have success and other times I don't. I try to remain calm and collected when doing the peer reviews, but rarely the stupidity of it gets to me. I wanted to see if anyone had better advise to give on how to approach the peer review process.

For instance, I do a peer to peer with another physician on a really solid IPR candidate and justify IPR to meet the standard criteria (patient needing PT, OT, SLP and has medical complexity, etc). Before the final determination it goes to the "supervisor" who I am not allowed to speak with or know who they are. Within 5-10 seconds the determination is that they can only go to a SNF. When asked further I literally was told "because the supervisor said so." Obviously a patient can request a written appeal, but most people chose not to since that can take too long.

So if you get a determination like that is it best to just leave it alone and not let it bother you. Or is there something else that people know what to do when you get a solid door slammed on the case.

 

[runfastnow]

I try to not let it bother me or figure out why it was denied to try and avoid the next time around with documentation, etc.. Anecdotally I've had good success on appeals by having patients advocate for themselves (both outpatient or inpatient) by calling the insurance company directly +/- giving them the file number. For inpatient it usually is the family advocating.

Most patients/families are willing and able to do so if they know I have done a peer-to-peer and/or everything I can do to get IRF admission, MRI, procedure, etc. approved.

It's all a game unfortunately.