Peer to Peers - How to fit into day? Tips?

[DrMDAware]

Any y'all got good tips for scheduling peer to peers?

So far I've heard:
1. Get better documentation
2. Have the PA/NP to do them
3. Step out of the room while seeing a patient
4. Create a window of time every week to do them like 1-2pm on Tuesdays, for example.
5. Make the patient come in to gather more information so you can bill

I hate #3. I'm leaning towards #4.

---

Members don't see this ad.

 

[RoloTomassi]

3. Only takes a couple minutes, just excuse yourself, say you've been waiting on a call from a doctor. I do maybe 1 a week, not a big deal.

2. If they know how to have a high success rate or it's pointless.

 

[Ligament]

Charge substantial money to do a peer to peer.
I need a 15 min window dedicated to a peer to peer.
You are loosing a lot of your time, paying your staff money to coordinate and schedule it, etc. It is a massive drain and cost.
Inform patient no positive outcome is guaranteed.

 

[myrandom2003]

So charge something like $75?

Say, your insurance is requiring us to call to discuss the case to approve your MRI/Procedure. We charge $75 for the time
Required to complete this and it is not guaranteed that they will
Still approve. Do you consent to the fee?
Alternatively, we can wait for them to deny, have you come back and we can review the denial and see what we need to do to get it approved.

Something like that?

 

[Agast]

How many are you finding yourself doing a week? It’s usually the same issues that pop up and you have to work that into your template.

 

[lobelsteve]

1 every 6 mo

 

[DrMDAware]

Charge substantial money to do a peer to peer.
I need a 15 min window dedicated to a peer to peer.
You are loosing a lot of your time, paying your staff money to coordinate and schedule it, etc. It is a massive drain and cost.
Inform patient no positive outcome is guaranteed.

I could be wrong I was told I couldn’t bill for a peer to peer? I agree with you about the time and resources drained.

So charge something like $75?

Say, your insurance is requiring us to call to discuss the case to approve your MRI/Procedure. We charge $75 for the time
Required to complete this and it is not guaranteed that they will
Still approve. Do you consent to the fee?
Alternatively, we can wait for them to deny, have you come back and we can review the denial and see what we need to do to get it approved.

Something like that?

Got it. And so if they come back and we review the denial we charge a regular visit then?

How many are you finding yourself doing a week? It’s usually the same issues that pop up and you have to work that into your template.

That’s fair. And I’ve found some holes before. Now though it seems like they’re not even reading my note. Not sure I should switch from paragraph to a checkbox template. I’ve tried using bold, putting it in all caps, putting it in a different color. I’m open to hearing suggestions!

For example
- genicular RFAs are experiential
- need letter of necessity (my note says all previous PT, meds tried, previous) injections etc
- did not document % relief -> it’s in my note

1 every 6 mo

Impressive!

____________________
Part of me thinks my benefits person is too lazy/dense to go through my note and get the information and automatically schedules a peer to peer when they’re asked questions.

 

[SSdoc33]

6. Dont do them


Problem solved

 

[Dr. Ice]

Agree, I don’t do them. For mri denials I offer them an outpatient radiology group that charges $300 for mri.

I don’t do procedure denial peer to peer. They can go to the many institutions down the block from me who have staff, time, better contracts than me to hold their hands during the process

 

[BobBarker]

Doesn’t happen too often. At my hospital practice, the prior auth people just set them up and they call whenever. I just jump out and do them. Don’t argue or be mean to the peer. They typically want to help you/the patient.

 

[geauxg8rs]

For injections and rare imaging request when the denial is egregious, I typically schedule at 4 when i am finishing up clinic. I am central time so half the time the lazy P2P schedulers say the doc leaves by 4 eastern so do it when we want. It is getting ridiculous.

Older patients are gratefu which is why i don’t just deny them outright. those under 30 think it’s my job to call the doctor to get their medication approved.
“I called my insurance and they said they just needed you to explain why you are needing that Med…”. Uh no way

 

[GoBeers]

i do a couple per year. mostly it's because i forgot to document percentage improvement, average pain score, other modalities attempted for x months. when I get on the phone, I don't even bother to make a case. I just ask what I'm missing and then make an addendum to my previous note or just wait until next visit.

one time I had an interventional pain peer to peer reviewer and he said I didn't document 6/10 pain. My note mentioned 3/10 pain, to which I explained "she was taking norco and had 3/10 pain. the point of RFA is to get her off norco right?" he said "just put in 6/10"

 

[Welcome123]

With the new 2021 em coding guidelines it allows for time spent on
§ ordering medications, tests, or procedures
§ referring and communicating with other health care professionals
This should absolutely count to the time code as it is part of the em coding and elevate the level of the visit code, as this is part of the test ordering process. The actual p2p time should count as well as the time getting through to the p2p.
The calls should be recorded so they can verify the times as well

 

[cowboydoc]

With the new 2021 em coding guidelines it allows for time spent on
§ ordering medications, tests, or procedures
§ referring and communicating with other health care professionals
This should absolutely count to the time code as it is part of the em coding and elevate the level of the visit code, as this is part of the test ordering process. The actual p2p time should count as well as the time getting through to the p2p.
The calls should be recorded so they can verify the times as well

…same day as visit.

 

[Welcome123]

…same day as visit.

From AMA
Discussion: Discussion requires an interactive exchange. The exchange must be direct and not through
intermediaries (eg, clinical staff or trainees). Sending chart notes or written exchanges that are within
progress notes does not qualify as an interactive exchange. The discussion does not need to be on the date
of the encounter, but it is counted only once and only when it is used in the decision making of the
encounter. It may be asynchronous (ie, does not need to be in person), but it must be initiated and
completed within a short time period (eg, within a day or two).

 

[Ligament]

So charge something like $75?

Say, your insurance is requiring us to call to discuss the case to approve your MRI/Procedure. We charge $75 for the time
Required to complete this and it is not guaranteed that they will
Still approve. Do you consent to the fee?
Alternatively, we can wait for them to deny, have you come back and we can review the denial and see what we need to do to get it approved.

Something like that?

Yes, exactly. 🙂

 

[Ligament]

I could be wrong I was told I couldn’t bill for a peer to peer? I agree with you about the time and resources drained.

You probably were told that. And it may be correct, depending on your state and contract. But screw that. Why would you waste 15 mins of your time and 15-30 mins of your staff time (interacting with patient over denial, talking to patient over denial, calling insurance company to schedule peer to peer, scheduling your time to do peer to peer, adjusting your schedule to make time for peer to peer, faxing new records to insurance company after you talk to "peer", etc ect). Is your time not how you make money?

 

[bedrock]

You probably were told that. And it may be correct, depending on your state and contract. But screw that. Why would you waste 15 mins of your time and 15-30 mins of your staff time (interacting with patient over denial, talking to patient over denial, calling insurance company to schedule peer to peer, scheduling your time to do peer to peer, adjusting your schedule to make time for peer to peer, faxing new records to insurance company after you talk to "peer", etc ect). Is your time not how you make money?

agree with this. I have started scheduling office visits concurrent with peer to peer to pay for my time as my practice won't allow me to bill the patient for the time. At least this way the insurance company pays an extra $100 and the peer reviewer fee which they should for wasting my time.

 

[ateria radicularis magna]

Who are these peers anyway ? Sometimes I google them and nothing much comes up.

 

[Agast]

Who are these peers anyway ? Sometimes I google them and nothing much comes up.

Back when I took workers comp I had a couple with a PM&R pain doc from California, he was pretty reasonable if I made the patient sound as pathetic as possible. There was a horrid b*tch who turned out to be employed by National Pain and Spine who denied duloxetine, only had to deal with her once. And another guy in San Antonio who once did the peer somewhere in the mountains during his vacation so I could barely hear what he was saying. He showed up again representing Humana and denied an SI joint injection because the patient hadn’t tried a TENS unit. If I ever run into him in person we will have words.

 

[deleted875186]

agree with this. I have started scheduling office visits concurrent with peer to peer to pay for my time as my practice won't allow me to bill the patient for the time. At least this way the insurance company pays an extra $100 and the peer reviewer fee which they should for wasting my time.

If we all started doing this, these peer to peer visits would magically go away. Once it starts costing the insurance payer money, problem solved.

 

[promethius]

I just did a peer-to-peer the other day on a MRI I ordered. The MRI was denied because the patient did not undergo the necessary number of weeks of therapy, but when I talked to the reviewer, an exception was made after I just reiterated what I wrote in my note. I usually do the peer-to-peer at the end of my day, usually concurrently while I am doing something else, as it is more-or-less a mindless exercise in futility; either they approve it or they do not.

 

[ateria radicularis magna]

Back when I took workers comp I had a couple with a PM&R pain doc from California, he was pretty reasonable if I made the patient sound as pathetic as possible. There was a horrid b*tch who turned out to be employed by National Pain and Spine who denied duloxetine, only had to deal with her once. And another guy in San Antonio who once did the peer somewhere in the mountains during his vacation so I could barely hear what he was saying. He showed up again representing Humana and denied an SI joint injection because the patient hadn’t tried a TENS unit. If I ever run into him in person we will have words.

Was the tens unit a necessity in the guidelines Humana employed him to follow ?

 

[Agast]

Was the tens unit a necessity in the guidelines Humana employed him to follow ?

Yes. Cohere health put it in their questionnaire.

 

[Welcome123]

P2P saves the insurance companies a great deal of money. It creates obstacles to care and makes doctors more reluctant to order tests. By delaying care and adding additional workload to already overburdened physicians they end up decreasing their spend.
It is divisive to physician and patient relationships as often the denial reason will blame physician documentation.
From a shareholder/profit perspective it is brilliant
From a policyholder perspective it quite often seems like the physicians fault.
From a physician perspective, it is frustrating, delays care/ treatment.
There is an interesting study on MRI of the lumbar spine by some physical therapist that suggests the MRI only adds to cost of care and should not be ordered as it is wasteful in terms of time and health insurance dollars. There may be some truth to that from a limited and ignorant perspective.
malpractice case such as the kaiser permanente case of the 18yo with an aggressive cancer that settled for around 28M$ specifically for failure to order a lumbar MRI

Jury Awards $28 Million Verdict

A jury awarded Anna Rahm a verdict of $28,215,278 in future medical expenses, future loss of earnings, and pain and suffering after a trial in LA Superior Court

shernoff.com

That malpractice settlement will not come out of any health insurance dollars-so it is still saves money for the health insurance company. They can deny the physician gets the blame.
I believe that currently the best way to do this is somehow involve the patient in the process so you can add a telehealth or same day discussion/visit for P2P and bill the insurance company for rhe discussion/visit with the patient

 

[Dr. Ice]

P2P saves the insurance companies a great deal of money. It creates obstacles to care and makes doctors more reluctant to order tests. By delaying care and adding additional workload to already overburdened physicians they end up decreasing their spend.
It is divisive to physician and patient relationships as often the denial reason will blame physician documentation.
From a shareholder/profit perspective it is brilliant
From a policyholder perspective it quite often seems like the physicians fault.
From a physician perspective, it is frustrating, delays care/ treatment.
There is an interesting study on MRI of the lumbar spine by some physical therapist that suggests the MRI only adds to cost of care and should not be ordered as it is wasteful in terms of time and health insurance dollars. There may be some truth to that from a limited and ignorant perspective.
malpractice case such as the kaiser permanente case of the 18yo with an aggressive cancer that settled for around 28M$ specifically for failure to order a lumbar MRI

Jury Awards $28 Million Verdict

A jury awarded Anna Rahm a verdict of $28,215,278 in future medical expenses, future loss of earnings, and pain and suffering after a trial in LA Superior Court

shernoff.com

That malpractice settlement will not come out of any health insurance dollars-so it is still saves money for the health insurance company. They can deny the physician gets the blame.
I believe that currently the best way to do this is somehow involve the patient in the process so you can add a telehealth or same day discussion/visit for P2P and bill the insurance company for rhe discussion/visit with the patient

Good points. I just don’t deal with it. $300 for a good quality spine mri. Patients can pay for it. They spend more than that to take their kids to the zoo or aquarium or museum. In document that the patients insurance company has denied their mri request and despite what I document on this medical record they continue to deny. Therefore it is the insurance company, not me that is responsible for continued pain and suffering on the part of the patient. I say these words in the medical record. Come at me if they want…

 

[Welcome123]

Good points. I just don’t deal with it. $300 for a good quality spine mri. Patients can pay for it. They spend more than that to take their kids to the zoo or aquarium or museum. In document that the patients insurance company has denied their mri request and despite what I document on this medical record they continue to deny. Therefore it is the insurance company, not me that is responsible for continued pain and suffering on the part of the patient. I say these words in the medical record. Come at me if they want…

I like your strategy. Unfortunately, I am unclear if that would be sufficient for an aggressive and biased lawyer.
Insurance companies are among the worlds wealthiest and most influential for profit systems.
Going against an insurance company is like walking into the ring as an untrained civilian and fighting a heavyweight that gets to change the rules without any fair disclosure, cheat with impunity, and retroactively change past victories.
As a whole, our lobbies seem ineffectual and the culture of medicine attracts and encourages criticism amongst one another enough so that we are all headed for increased liability/administrative/regulatory burden. Things will need to get dramatically worse for any strong united physician efforts to develop.

 

[ateria radicularis magna]

Does a p2p come from an insurance company ? I thought they came from companies hired by the insurance companies ?

 

[bedrock]

Does a p2p come from an insurance company ? I thought they came from companies hired by the insurance companies ?

doesn't matter. having the patient come in for a f/u while you do the peer to peer, cost the insurance companies money, which they deserve to lose for denying care that the physicians understand better than the corporate bean counters

 

[geauxg8rs]

doesn't matter. having the patient come in for a f/u while you do the peer to peer, cost the insurance companies money, which they deserve to lose for denying care that the physicians understand better than the corporate bean counters

Half the time I am literally reading my note word for word. I now put 6 out of the last 6 weeks the patient did physician directed exercises in my note. This couldn’t be a more “recent trial of therapy.”

Because they try to say “you don’t specify that the exercise is recent”

Sometimes they try to say “what exercises?”

And I say “physician prescribed”
Then they say “we need to know which kind”

And I say “I am looking at your denial note which says…(i read it verbatim and it doesn’t list specific exercises, just have to be physician prescribed/directed)” at this point they try to spew some off script nonsense and I just talk over them

I need your name, license number, extension, supervisor name and extension. I am going to file a complaint with the state insurance commissioner for delaying or denying care that should have been approved a week ago.

Then 9/10 times. Can you hold for the approval number…

 

[ateria radicularis magna]

Half the time I am literally reading my note word for word. I now put 6 out of the last 6 weeks the patient did physician directed exercises in my note. This couldn’t be a more “recent trial of therapy.”

Because they try to say “you don’t specify that the exercise is recent”

Sometimes they try to say “what exercises?”

And I say “physician prescribed”
Then they say “we need to know which kind”

And I say “I am looking at your denial note which says…(i read it verbatim and it doesn’t list specific exercises, just have to be physician prescribed/directed)” at this point they try to spew some off script nonsense and I just talk over them

I need your name, license number, extension, supervisor name and extension. I am going to file a complaint with the state insurance commissioner for delaying or denying care that should have been approved a week ago.

Then 9/10 times. Can you hold for the approval number…

Haha
Do they tell you their name and license number ?
Do you report them ?
Seems like this set up is only useful perhaps in reducing procedure volume for those multi np setups who try every possible procedure on every possible patient. Devils advocate…without a check on these practices clearly over utilizing every procedure, doesn’t coverage and reimbursement suffer for docs practicing honestly ?

 

[ateria radicularis magna]

If we all started doing this, these peer to peer visits would magically go away. Once it starts costing the insurance payer money, problem solved.

100$ is a tiny fraction of a cost for 2 mbb and then an rf once a year for the next 9 years, though, right?

 

[SSdoc33]

so you guys are doing a P2P at the end of the daym when all you want to do is get home, go for a workout, pick up the kids, or make dinner?

you'd rather spend waste your time arguing with a bean counter who has never even met your patient? o.......k

just wait the extra 1-2 days for the formal denial. everything they would have said in the peer to peer, they spell out verbatim in writing. if you do the peer to peer, then they don't even need to do their work on their end. i don't think they even need to make a formal report (though I'm not 100% sure).

just briefly glance at the denial, change up your language a touch, resumbit, and you are done.

i just saved you guys 15-30 mins/week.

 

[geauxg8rs]

Haha
Do they tell you their name and license number ?
Do you report them ?
Seems like this set up is only useful perhaps in reducing procedure volume for those multi np setups who try every possible procedure on every possible patient. Devils advocate…without a check on these practices clearly over utilizing every procedure, doesn’t coverage and reimbursement suffer for docs practicing honestly ?

Some tell me and some don’t. Most do tell me. Most say they don’t have a supervisor.
I am not going to report them. Waste of time. But it at least is an empty threat that works on some. I guess they will just deny the next three from someone else to make up for it.

 

[Welcome123]

so you guys are doing a P2P at the end of the daym when all you want to do is get home, go for a workout, pick up the kids, or make dinner?

you'd rather spend waste your time arguing with a bean counter who has never even met your patient? o.......k

just wait the extra 1-2 days for the formal denial. everything they would have said in the peer to peer, they spell out verbatim in writing. if you do the peer to peer, then they don't even need to do their work on their end. i don't think they even need to make a formal report (though I'm not 100% sure).

just briefly glance at the denial, change up your language a touch, resumbit, and you are done.

i just saved you guys 15-30 mins/week.

Unfortunately, denial reasons are not always explicitly stated.
What I typically do is search for the latest clinical policy bulletin (CPB) then cut and paste into my note. This seems to have an 80-90% success rate.
Of the ones that still get denied, when I get to the P2P and I ask why it was denied after according to their own policy bulletin it should be approved, several times the response has been “I don’t know, this should have been approved”
Most recently, I cited the Aetna CPB on a denied MRI and the answer for the denial reason was (for the patient who had an Aetna plan), “we don’t use Aetna guidelines we use Evicore”🤷‍♂️

 

[jewwithguitar]

doesn't matter. having the patient come in for a f/u while you do the peer to peer, cost the insurance companies money, which they deserve to lose for denying care that the physicians understand better than the corporate bean counters

Just to clarify: you are scheduling the P2P at the time of the patient's visit and then have the patient present in the room while you perform the P2P phone call? Are you billing this as 99213/4? Are you documenting anything specific in the note in regards to the P2P?

 

[BobBarker]

Do you tell the peer you have the patient with you and do it on speaker phone?

 

[clubdeac]

I get one to two MRI denials a week. It’s almost always for failure of 6 weeks of PT or physician directed care prior to the request. It’s super annoying bc they’ve almost always had 6 weeks of therapy and it’s documented in my notes. When I get on the phone they always deny having my notes which is a lie. Such a waste of time

 

[Ducttape]

Half the time I am literally reading my note word for word. I now put 6 out of the last 6 weeks the patient did physician directed exercises in my note. This couldn’t be a more “recent trial of therapy.”

"within the last 6 months, the patient has done over 6 weeks of home exercise that i personally instructed the patient"

its the physician directed care part from the physician ordering the MRI that they point to.