Peer to peer
Started by Billy Jack
Are you the peer-er or the peer-ee in this scenario?
I’ve seen workers comp peer reviewers get bad reviews from patients who figured out who denied their treatment…
I saw that - and couldn't agree more. In rehab, now 100% of Medicare Advantage plans for example deny rehab. I get to do P2P on every patient with the same "peer" from the insurance company and had to let this person know - since all your denials were overturned in appeals by the family, I question your clinical judgment to begin with. This "physician" didn't appreciate that, she tells me. I told her I didn't appreciate her denying 100% of my patients that were appropriate for rehab. Many denials are complete and utter garbage.
I'm not sure how a peer reviewer can give you a bad review. They don't work with you or for you.
insurance is using more AI to determine authorization for procedures. Interestingly, Humana recently decided to leave the private sector and go to Medicare advantage and government backed plans only. I’m guessing they’re cutting costs by decreasing personnel?
apnews.com
Insurer Humana lays out employer-sponsored coverage exit
The health insurer Humana will stop providing employer-sponsored commercial coverage as it focuses on bigger parts of its business, like Medicare Advantage.
apnews.com
Some doctors signing up for these gigs are being told to "call out" other doctors by their supervisors. We need our specialty societies to step up an oppose this stuff.
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.
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 for profit medicare advantage plans are really terrible. There is national action going on against them as their denial rates 2x-3x other insurances.
Had an obgyn peer to peer deny an RFA for a patient the other day
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For what reason?
Some BS things - it “didn’t meet medical necessity” bc her last mri was like a year old or some bs .
My PAs do all the P2P. Their success rate is as good as mine ever was
Mine do a lot too. Sometimes they won't let them.
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.
How does that work with getting a judge involved? I’ve never done that before.
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.
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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."
Well clearly legislation is being worked on, not to mention that typically once family appeals are done, patients in 80-90% of the time win - so if anything that leads to increased costs for the insurance company which is just plain stupid for them. A lot of these physicians should lose their license.
Many patients do change their insurances routinely - everything in life including medicine is a pendulum.
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
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.
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%.
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%.
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
D
deleted131481
This is what I've been doing last 6 months. My stress level and frustration with the process has dramatically declined.
On a side note, what kind of pay so those physicians working on these insurance panels make? Sounds worse than a terrible direct patient care set-up. Work from home maybe an advantage?
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I never heard of such a thing before. Basically, Medicare advantage plans are legally obligated to cover something that traditional Medicare would. The commercial carrier, i.e., Aetna Medicare, united Medicare, etc. denies it. and Relievant exhausts all appeal options. Relievant then coordinates getting it set up with an administrative law judge hearing via phone. I give a one minute summary of the patients clinicals, indications for procedure, and state I have done X Medicare cases,
and all have been fully covered by Medicare. The Relievant rep on the phone then reviews the Medicare policy and applicable laws. Patient gets a few minutes to talk. Usually we then get a letter in the mail about a month or so later with the judge overturning the Medicare advantage plan decision.
Insurance: Patient has to fail at least 6 weeks of treatment
Me: I wrote in my note it’s been going on for 3 months
Insurance: resubmit it as 6 weeks
i’m so glad i gave up 9 years of my life to train up for this ****
I was covering inpatient rehab consults once and Blue Cross denied a new CVA patient with significant deficits. The peer was actually a former PM&R doc at our rehab hospital. I get a page from the rehab hospital CEO who said he’ll go to the mat for this one because he’s the one that originally fired her. So of course that one got approved.
Insurance: SCS trial is approved only for failed back syndrom and considered investigational for all else. your request for failed back syndrome is denied.
Me to peer to peer: "Syndrome is spelled with an 'e' at the end."
peer to peer, after extended pause: "The auth number is..."
Me to peer to peer: "Syndrome is spelled with an 'e' at the end."
peer to peer, after extended pause: "The auth number is..."
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.
