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Has anyone gotten a bad review from a peer reviewer who denied a procedure for your patient?
Are you the peer-er or the peer-ee in this scenario?Has anyone gotten a bad review from a peer reviewer who denied a procedure for your patient?
Has anyone gotten a bad review from a peer reviewer who denied a procedure for your patient?
Had an obgyn peer to peer deny an RFA for a patient the other day
Some BS things - it “didn’t meet medical necessity” bc her last mri was like a year old or some bs .For what reason?
Mine do a lot too. Sometimes they won't let them.My PAs do all the P2P. Their success rate is as good as mine ever was
How does that work with getting a judge involved? I’ve never done that before.I have done several administrative law judge hearings for Medicare advantage, patients for intracept. Knock on wood, but all thus far have been overturned by the judge. Completely ridiculous it has to get to that point.
Exactly. Reviewers sadly are not only not peers but frequently physicians who have had issues practicing. And I have done just that stating that I will put in my note who is denying care so that if any legal issues come up they will know who to sue. They don’t like that. We need to start calling out physicians who deny care inappropriately.Had a friend Sports Med doc tell me had surgery for osteomyelitis denied as patient had not tried PT first.
Peer reviewer was hostile. 4 years out of residency as a Pediatrician.
Let them know precedent from MN law. Peer reviewers can be held accountable for medmal.
The Medicare advantage “doctors” frequently don’t even follow guidelines and make up their own guidelines which is against the law. Somehow they think no one will notice?Texas passed a law stating the peer to peer has to be the same specialty. I did get a few neurosurgeons but I guess that falls under the “spine” umbrella. On the plus side they understand when patients are not surgical candidates.
The Medicare advantage “doctors” frequently don’t even follow guidelines and make up their own guidelines which is against the law. Somehow they think no one will notice?
...no one will notice.
What you think is gonna happen? They choose to deny your ESI and you have a problem with it? Too bad. You're powerless.
The pt can leave that company and use the free market to exact their punishment against the insurer, but how many can or will do that?
They usually just suffer or start Percocet.
I've reminded P2P docs we're on a recorded call and they don't care.
"You realize this call is being recorded and you sound like a ***** right? I'd love to play this recording at a society meeting during one of the lunch breaks. It's great comedy."
read the denial, addend your note. resubmit.I do them. I understand your position, but I disagree with it.
read the denial, addend your note. resubmit.
if that fails, have your extender call.
if that fails or dont have an extender, feel free to sit on hold and embarrass the "peer". i suppose it works sometimes
no.Frequently they don't give a reason for denial. Most of them have no idea what they are talking about, and sadly not a small number of reviewers barely speak comprehensible English. They have no understanding of the specialist they are talking to because they tend to be primary care doctors - internists or pediatricians seem to be high on the list. Frequently they can't even list the Medicare criteria.
I had one idiot tell me I was wrong on the criteria, I said oh really? Please pull them up. As this "medical director" pulls up the criteria, he realizes that everything I told him was right and that he was way off.
He looked like an idiot but that didn't stop him. Family appeals, of course overturned. Pure idiocy.
This is what I've been doing last 6 months. My stress level and frustration with the process has dramatically declined.read the denial, addend your note. resubmit.
if that fails, have your extender call.
if that fails or dont have an extender, feel free to sit on hold and embarrass the "peer". i suppose it works sometimes
How does that work with getting a judge involved? I’ve never done that before.
no.
they always have a formal, written denial.
they just "request" a peer to peer before sending the formal denial. dont fall for the trick. wait for the paperwork, then see what the issue is. usually its PT, or your didnt mention the pain scale or % pain relief. those are easy to fix without talking to some dolt. if its lack of PT, then there isnt all that much wiggle room
the ones I hate are the LOL with severe stenosis who barely move anyway and are forced to endure PT. that bugs me
Lol.peer to peer...
one was denied because inadequate pain relief from MBB. no documentation of 80% reduction of pain.
my response: i documented100% reduction of pain. 100% is greater than 80%.
Insurance: Patient has to fail at least 6 weeks of treatmentpeer to peer...
one was denied because inadequate pain relief from MBB. no documentation of 80% reduction of pain.
my response: i documented100% reduction of pain. 100% is greater than 80%.
Serious concerns? Already well known that these are artificial hurdles created to deny procedures. One of the many strategies used by payers to weasel their way out of making payments.
Consider letting the pt know that she can try one session of PT. If the pt reports that PT worsened her pain you can try to reauth the procedure. Sometimes documentation that PT worsened the pt's pain or the pt is refusing to receive more PT because of worsening pain will be adequate to receive approval for the procedure.no.
they always have a formal, written denial.
they just "request" a peer to peer before sending the formal denial. dont fall for the trick. wait for the paperwork, then see what the issue is. usually its PT, or your didnt mention the pain scale or % pain relief. those are easy to fix without talking to some dolt. if its lack of PT, then there isnt all that much wiggle room
the ones I hate are the LOL with severe stenosis who barely move anyway and are forced to endure PT. that bugs me