TIps for Peer to Peer reviews

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gator2886

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Any tips on handling peer to peer reviews? In particular with one abrasive, rude reviewer who is trying to deny a Cervical epidural because the patient has only subjective findings (which are well documented). Pt also has MRI supporting diagnosis. Pt has no weakness, sensory loss or DTR affected (like many). Pt clearly needs it and I do not understand why they are even trying to deny. TONS of patients have radiculopathy without objective findings.
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In the case of unreasonable reviewer who is determined to deny it, take it on the chin and then file an appeal. Unlikely to get two crazy reviewers in a row.
 
Specify everything that patient did in assessment and plan

.....

Last but not least, ask for the “peers” full name, state of practice, and license number. Let them know that you’ll document their names in the chart and that you spoke to them directly.

I had a few phone calls back and things magically are approved “after thinking about it”
 
When I am on with a doctor I read them their own company policy for mri or procedure auth. It is in their denial paperwork. 9/10 it is for failure of conservative care.

Once an mri was denied for lack of conservative care despite the patient having motor loss. I read them their policy and they had to approve it.



last battle was for an mri of the lumbar spine. The notes that i submitted clearly stated 6 weeks of PT over the past 6 weeks without relief. Should have been easy approval. Got denied.
The reviewer told me that they needed the PT notes. I told them that their guidelines do not require PT notes just recent conservative care failure for 6 weeks. I told them that I read their guidelines word for word. The guy tried to argue with me.
That’s when you need to go with a chip on your shoulder. Say I need your name, extension, license number, their supervisor and extension. Then say that this should be approved per their company guidelines and if not approved within 24 hours that I will file complaint on patient behalf with state insurance commission and the state AG. That this denial is causing the patient further undue disability.

approved later that day
 
gator2886 said:
Any tips on handling peer to peer reviews? In particular with one abrasive, rude reviewer who is trying to deny a Cervical epidural because the patient has only subjective findings (which are well documented). Pt also has MRI supporting diagnosis. Pt has no weakness, sensory loss or DTR affected (like many). Pt clearly needs it and I do not understand why they are even trying to deny. TONS of patients have radiculopathy without objective findings.
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Read the specific policy. Some states comp requires documented radiculopthy matching the pathology. A note stating radicular arm pain is not adequate. Needs to match the specific compressed nerve dermatome for instance to the specific level of herniation.
 
MRI denial for a pt I'm sending for an L2-S1 vs L2-L5 reconstruction. She has severe spinal and foraminal stenosis on an MRI in Feb 2017. I am updating the MRI for the surgeon.

Peer asked me, "Is she weak? You didn't document that on your note."

"I picked the patient up out of her wheelchair and placed her on the exam table." That is documented.
 
Orin said:
You just wanted to show off your guns. She might could've done it on her own.
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...ain't what they used to be...

I need TRT and a motorcycle.
 
nynydoc said:
Specify everything that patient did in assessment and plan

.....

Last but not least, ask for the “peers” full name, state of practice, and license number. Let them know that you’ll document their names in the chart and that you spoke to them directly.

I had a few phone calls back and things magically are approved “after thinking about it”
Click to expand...

Yes but you need to get their info first before getting into case specifics, otherwise they will hang up on you
 
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I have had patients with cancer histories get MRIs denied. When I have the peer to peer, the “peer” tells me it’s because “history of cancer”is diagnosis #2 on the MRI order and #1 is lumbar radiculopathy. They only count #1. They never read the actual note. I’ve since put history of cancer as #1 whenever a patient has that history and haven’t had any more denials.
 
MD87 said:
I have had patients with cancer histories get MRIs denied. When I have the peer to peer, the “peer” tells me it’s because “history of cancer”is diagnosis #2 on the MRI order and #1 is lumbar radiculopathy. They only count #1. They never read the actual note. I’ve since put history of cancer as #1 whenever a patient has that history and haven’t had any more denials.
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Same thing happens with opiate prescription denials for cancer pain
 
Biggest tip i can give you on a peer-to-peer: don't do them. what happens when you "win" a peer-to-peer? you spend a half hour of your life without getting paid for it? it is sort of like beating a 5 year old in a 1-on-1 basketball game.

your best bet is to have all your documentation in order, especially with insurances that are know to be bad players. then, get the formal/written denial, add an addendum with a bit of a stretching of the truth as you see fit, and then resubmit for authorization.

it doesnt make sense to play a game when only 1 side plays fairly
 
Yes p to p are lose lose. Waste of time for a procedure that pays a couple hundred bucks. Sucks for the patients most of all. This is their game. They know it’s not worth it and so many won’t fight it.
 
It’s just a blatant attempt at wasting your time and frustrating you. I personally won’t play the game.
 
22 min peer to peer today to get mris approved for blue crock...
Step one listen to menu, step 2 talk to data entry minion , wait on hold, step 3 talk to smug nurse minion who asks “clinical questions,” step 4 wait on hold for a long time, step 5 speak to doctor minion who asks all the same questions as the smug nurse and data entry minions then acts as if she is doing me a favor by approving the mri.
I wouldn’t have done it but I truly believed it needed to be done ASAP.
I was so angry.
 
I never thought I would miss Evicore but they’ve been replaced by Aim specialty health and their peer reviewer is a giant B.
 
geauxg8rs said:
With imaging it just leads to pcps ordering a useless X-ray and referring to pain management to get the mri.
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Yep. As a PCP that's exactly what happens. I get an x-ray that I know is pointless but I'll never get an MRI approved without it. Still gets denied, so I send the patient to y'all.
 
Agast said:
I never thought I would miss Evicore but they’ve been replaced by Aim specialty health and their peer reviewer is a giant B.
Click to expand...
but AIMs guidelines are public listed. Just make your templates to fit their requirements. Evicore is still the worst. They don't even look at notes. They just deny first.

Those that don't do P2P, what do you do instead? Anyone in private practice ask the patient if they want a p2p completed despite the most likely outcome already known, and charge them for doing it? I have a lot of patients that call the insurance, and the insurance tells them, that I just need to call to get it approved. Obviously a lie.
 
Aim sucks. Denied mbb because the patient also had leg pain. A holes. Honestly wish we could all stop accepting patients that used aim.
 
VA Hopeful Dr said:
Yep. As a PCP that's exactly what happens. I get an x-ray that I know is pointless but I'll never get an MRI approved without it. Still gets denied, so I send the patient to y'all.
Click to expand...

I get it and most of us know this game so we understand. But please order PT or start them on a “physician directed home exercise program” before they come to us so the 6 week clock has started by the time they get into our office 4 weeks later. If you were referring to me I’d even help you out with the exercise regimen handout.
 
myrandom2003 said:
but AIMs guidelines are public listed. Just make your templates to fit their requirements. Evicore is still the worst. They don't even look at notes. They just deny first.

Those that don't do P2P, what do you do instead? Anyone in private practice ask the patient if they want a p2p completed despite the most likely outcome already known, and charge them for doing it? I have a lot of patients that call the insurance, and the insurance tells them, that I just need to call to get it approved. Obviously a lie.
Click to expand...

I find out why it was denied, tell the patient what they need to do, have them do it then resubmit with updated documents.
 
DOctorJay said:
I get it and most of us know this game so we understand. But please order PT or start them on a “physician directed home exercise program” before they come to us so the 6 week clock has started by the time they get into our office 4 weeks later. If you were referring to me I’d even help you out with the exercise regimen handout.
Click to expand...
wont help...

have had multiple conversations from P2P - the "clock" of when the magic 6 week period starts is when WE give them the exercise, not some other physician. ie the ordering doc has to give the exercises.

though that other physician can order the MRI if it has been 6 weeks since they saw the patient, generated the referral, and gave exercises...
 
that's interesting, it certainly works for formal PT and chiropractic in my region. I didn't realize the physician guided program wouldn't work.
 
Ducttape said:
wont help...

have had multiple conversations from P2P - the "clock" of when the magic 6 week period starts is when WE give them the exercise, not some other physician. ie the ordering doc has to give the exercises.

though that other physician can order the MRI if it has been 6 weeks since they saw the patient, generated the referral, and gave exercises...
Click to expand...
I would demand to know what page and paragraph it states in their guidelines. They just make this crap up
 
unfortunately:


page 29 (of 62) from evicore, for axial back pain, as an example:
Failure of recent (within 3 months) 6-week trial of provider-directed treatment.

or page 33 for radicular back pain.
Failure of recent (within 3 months) 6-week trial of provider-directed treatment.

or page 43 for lumbar spinal stenosis.
Failure of 6 week trial of provider-directed treatment and clinical re-evaluation

when I have called, the only point to argue is whether a generic "provider" is okay or it has to be you. the answer has been that it has to be the one ordering, as that it the provider they are talking to.
 
SSdoc33 said:
Biggest tip i can give you on a peer-to-peer: don't do them. what happens when you "win" a peer-to-peer? you spend a half hour of your life without getting paid for it? it is sort of like beating a 5 year old in a 1-on-1 basketball game.

your best bet is to have all your documentation in order, especially with insurances that are know to be bad players. then, get the formal/written denial, add an addendum with a bit of a stretching of the truth as you see fit, and then resubmit for authorization.

it doesnt make sense to play a game when only 1 side plays fairly
Click to expand...
this....i keep asking my staff for the peer to peer code so i can bill. They keep telling me there is none. The peer reviewer isnt doing it for free. So i ask patient to come back and i call after they get another visit.....paid for by them.
 
Ducttape said:
wont help...

have had multiple conversations from P2P - the "clock" of when the magic 6 week period starts is when WE give them the exercise, not some other physician. ie the ordering doc has to give the exercises.

though that other physician can order the MRI if it has been 6 weeks since they saw the patient, generated the referral, and gave exercises...
Click to expand...
a HEP works and counts as PT per their guidelines....until they change their guidelines.
 
another tactic is to get your staff to get the peer reviewer on hold to wait for you. But some peer reviewer companies have a secretary talk to the treating dr(you) to SCHEDULE a peer to peer. Ive called thinking i was doing a peer to peer only to find out i was calling to schedule a peer to peer....more salt in the wound.
 
Doctodd said:
another tactic is to get your staff to get the peer reviewer on hold to wait for you. But some peer reviewer companies have a secretary talk to the treating dr(you) to SCHEDULE a peer to peer. Ive called thinking i was doing a peer to peer only to find out i was calling to schedule a peer to peer....more salt in the wound.
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More infuriating than the dmv.
 
callmeanesthesia said:
How do you make sure you have the doctor on? Half the time I get a call center that says they’ll page the doctor, and then no call back, or a call back an hour later.
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It hasn't been a major issue. I make sure the patient knows on the front end this is 100% an insurance thing. They often call and complain to their insurance. Have had plenty suddenly authorized that way, no work from myself or staff.
 
I just don’t do them and I tell the patient I’m not fighting with your insurance company. Most of the time MRI denials are for lack of PT bs..if acute pain I tell them I will document my findings and necessity for mri but I’ll also tell them that their insurance company doesn’t care that their arm is gonna fall off and that they most likely have to attempt PT. They will do it for like 2 sessions and then I can get it authorized.

Lately PA blue cross and subsidiaries been denying intra-articular facets and no chance in hell to get authorized. Guess I’m gonna be doing a lot more Rfa for my PA patients
 
Try to reason with them . If they are unreasonable, tell them to f...k off.
 
Well...... I just got off the phone with one.

Trying to justify a repeat RF in the T spine for recurrent axial back pain. Last one 7 months ago, but for T-spine I just don't typically get more than that in the few I do. Insurance company made me get a new MRI- (What an unnecessary waste), insurance cronies read no notes, and quite frankly just really annoyed me.

She let me know what else they needed, (new visit, new exam, new notes justifying old stuff). anyways I asked for her name and she informed me its Dr. blablabla - which is my pet peeve. She hung up on me after I asked her if her parents named her Doctor.

Any tips on how not to get so annoyed. Maybe not do them on a Monday or maybe later in the day when I can have a beverage on hand?
 
Can anyone tell me what the insurance companies are required to give us when they make a denial? I asked for the name and CV of the person who reviewed my last denial and they would not give it to me
 
Crybaby said:
Well...... I just got off the phone with one.

Trying to justify a repeat RF in the T spine for recurrent axial back pain. Last one 7 months ago, but for T-spine I just don't typically get more than that in the few I do. Insurance company made me get a new MRI- (What an unnecessary waste), insurance cronies read no notes, and quite frankly just really annoyed me.

She let me know what else they needed, (new visit, new exam, new notes justifying old stuff). anyways I asked for her name and she informed me its Dr. blablabla - which is my pet peeve. She hung up on me after I asked her if her parents named her Doctor.

Any tips on how not to get so annoyed. Maybe not do them on a Monday or maybe later in the day when I can have a beverage on hand?
Click to expand...

I used to get so mad at these people. Now I act like they’re my friends (seriously) and they end up helping me out. It must throw them off not to be treated poorly because they are wasting so much time for physicians.

They don’t always approve what I’ve ordered but they will tell me what needs to be documented or done or if there’s just no chance in hell of getting something approved based on the patient’s policy.
 
DOctorJay said:
I used to get so mad at these people. Now I act like they’re my friends (seriously) and they end up helping me out. It must throw them off not to be treated poorly because they are wasting so much time for physicians.

They don’t always approve what I’ve ordered but they will tell me what needs to be documented or done or if there’s just no chance in hell of getting something approved based on the patient’s policy.
Click to expand...
Thanks DoctorJay
Just tried this method and even though I did not get the answer I wanted the doc was way more helpful with giving me appeal options.
Added plus- my BP did not get high enough for me to stroke out 🙂
 
One of the nice things about the fellowship I went to is that we handled all the P2Ps so I got a good sense of what I need to put in my notes to not get denied with this I've only had to do ~3 P2Ps over the last 1.5 years and on almost all of them they either didn't get faxed the right notes or they didn't read them. I just have my MA call and set up the appointment with the P2P doctor so I don't have to wade through the menu and often it is a very painless 3 minute conversation with the reviewer.
 
DOctorJay said:
I used to get so mad at these people. Now I act like they’re my friends (seriously) and they end up helping me out. It must throw them off not to be treated poorly because they are wasting so much time for physicians.

They don’t always approve what I’ve ordered but they will tell me what needs to be documented or done or if there’s just no chance in hell of getting something approved based on the patient’s policy.
Click to expand...
Me too. Every so often you get a very helpful one who asks “so the patient has tried x, y, and z, and it didn’t help, right?”
 
I had a guy tell me to do an SIJ for free, and while I'm at it do an L4-S1 MBB and bill for that.
 
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