Why is peer-to-peer review such a joke?

[Therapist4Chnge]

I just had a P2P or at least attempted to have one. I get a fax requesting a P2P, providing a window of time of a whopping 1.5 days, where I have to respond w dates and times a reviewer can contact me. Per usual, the reviewer calls OUTSIDE of the times, and they leave a VM saying it is denied. Usually they call at 4:55pm on a Friday or during lunchtime, but yet another P2P w zero interest in actually having an honest and brief chat about treatment.

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[WisNeuro]

I've only done this a coupe times when the insurer denied prior auth. Unfortunately the "peer" reviewer was some hack who teaches at a local diploma mill who said I should be able to adequately assess a complicated movement disorder+cog impairment pt in 4 hours total (interview, testing, scoring, report writing, feedback). And hence followed one of my formal complaints to the department of health, as well as several supervisors at said insurance company. I never had a denial like that again from that one.

 

[WisNeuro]

But, to get back to the original question, if your region is anything like mine, these peer review jobs pay terribly, so they are likely staffed by diploma millers who couldn't find a job elsewhere and went wherever they could to make the loan payments on the six figure money they stupidly took out because they don't know how math works.

 

[futureapppsy2]

On the flip side, some of my physician colleagues say they have to do P2P for obviously needed things, and the peer reviewers are like "sure, of course. Duh." So, it may just be luck of the draw.

 

[Sanman]

I've only done this a coupe times when the insurer denied prior auth. Unfortunately the "peer" reviewer was some hack who teaches at a local diploma mill who said I should be able to adequately assess a complicated movement disorder+cog impairment pt in 4 hours total (interview, testing, scoring, report writing, feedback). And hence followed one of my formal complaints to the department of health, as well as several supervisors at said insurance company. I never had a denial like that again from that one.

A lot of Level 1 peer reviewers have not been psychologists in my experience (though I am not sure if this differs for neuropsych). The higher up review jobs I recall being paid pretty well when I looked at the jobs a few years back. More than VA money anyway.

 

[Sanman]

I just had a P2P or at least attempted to have one. I get a fax requesting a P2P, providing a window of time of a whopping 1.5 days, where I have to respond w dates and times a reviewer can contact me. Per usual, the reviewer calls OUTSIDE of the times, and they leave a VM saying it is denied. Usually they call at 4:55pm on a Friday or during lunchtime, but yet another P2P w zero interest in actually having an honest and brief chat about treatment.

Because they are literally being paid to waste your time while you are not being paid to fight back. That is what they want. Any denial of service is a win for them.

 

[WisNeuro]

A lot of Level 1 peer reviewers have not been psychologists in my experience (though I am not sure if this differs for neuropsych). The higher up review jobs I recall being paid pretty well when I looked at the jobs a few years back. More than VA money anyway.

I imagine it varies by region and insurer. The one that BCBS contracted with here had pretty laughable rates for doctoral providers.

 

[Therapist4Chnge]

But, to get back to the original question, if your region is anything like mine, these peer review jobs pay terribly, so they are likely staffed by diploma millers who couldn't find a job elsewhere and went wherever they could to make the loan payments on the six figure money they stupidly took out because they don't know how math works.

Just based on the person's signature block I can tell they are a hack. Insurance companies often will hire diploma mill ppl, have them get licensed in 6-10+ states, and they do volume reviewing. Every now and then I run into a well trained reviewer who is doing it for some side money, but the real volume reviewers are exactly the people you think would be doing it.

I just received the rejection letter and just like I thought....said they called at lunch and at 5-something yesterday...outside of the times I gave them. I'm going to file an appeal because their rationale was junk and a complete copy and paste review. I just hate that their "work" is complete trash, but I have to waste my time responding to their trash or the patient loses out. I definitely will file complaints when warranted, but mostly it's just shotty and lazy work.

 

[Therapist4Chnge]

On the flip side, some of my physician colleagues say they have to do P2P for obviously needed things, and the peer reviewers are like "sure, of course. Duh." So, it may just be luck of the draw.

It's definitely luck of the draw. I've had some solid P2P where the reviewer was openly annoyed it got kicked up to them because the medical necessity was clear, but the "average" are hacks who rarely even review the paperwork because every question they ask was already covered in the documentation.

 

[PsyDr]

You're right, they don't want to have a talk about treatment. They have a specific set of criteria that need to be met. They want to talk to you about how you explicitly meet that criteria. That's it.

You HAVE to know those criteria, which you can easily access. Otherwise, you're going to lose.

 

[Therapist4Chnge]

Their criteria include treatment-related things....like demonstrating improvements, the # of sessions utilized, and documenting said improvements. They cited the # of treatment dates recommended (6-10) as met. My counselor used 6 and documented the above, and the response was....they hit the minimum number, therefore treatment is done.

 

[PsyDr]

Bet you it was also the time frame.

(I yelled at a former APA president who was doing peer review for that).

 

[erg923]

I just had a P2P or at least attempted to have one. I get a fax requesting a P2P, providing a window of time of a whopping 1.5 days, where I have to respond w dates and times a reviewer can contact me. Per usual, the reviewer calls OUTSIDE of the times, and they leave a VM saying it is denied. Usually they call at 4:55pm on a Friday or during lunchtime, but yet another P2P w zero interest in actually having an honest and brief chat about treatment.

If this was an internal Psychologist/Physician Reviewer (vs a contracted agency like FOCUS or BHM?), I would certainly complain to your company contact!!!

The rationale for designated time windows is that it lessens the burden and makes it easier and more flexible for both parties. To openly flaunt that is rude....and produces unnecessary provider abrasion. Probably not what any insurance company really wants to do. As an overall supervisor of corporate utilization management (UM), I would definitely want to know if that was happening. And who did it.

Further, strict adherence to medical necessity criteria/guidelines such as Interqual or MGC is NOT the proper way to approach a Peer-to-Peer reconsideration and should often fall into the background during a telephonic Peer-to-Peer reconsideration conversation...so long as the treating provider gives additional clinical information that was not considered during the initial medical necessity review.

 

[erg923]

Unfortunately the "peer" reviewer was some hack who teaches at a local diploma mill who said I should be able to adequately assess a complicated movement disorder+cog impairment pt in 4 hours total (interview, testing, scoring, report writing, feedback).

That's not really a reason other than maybe he/she thought that and/or Interqual said so. A telephonic Peer-to-Peer conversation would be obliged to explain that reasoning in a clinically nuanced and empirically supporter manner. Many times, formal denial letters cannot get into super specific clinical rationales due to complexity and the reading level standards set my NCQA. If the peer reviewer subsequently can't justify it other than it being the company/party line or "that's what I think"...I agree you have right to think they are a dummy!

 

[erg923]

Just based on the person's signature block I can tell they are a hack. Insurance companies often will hire diploma mill ppl, have them get licensed in 6-10+ states, and they do volume reviewing.

Would have to disagree. While 3rd party contractors may have low standards and pay per case (but NOT per denial of course), psychologists hired directly by the big 5 managed care companies (whether its is for direct UM operations or research or clinical leadership functions) have to have pretty outstanding backgrounds. At least on paper. Its actually one of the places that targets the clinical science folks from Berkley and alike in which we always ask.... where are the jobs for these people?!

 

[ClinicalABA]

It's definitely luck of the draw. I've had some solid P2P where the reviewer was openly annoyed it got kicked up to them because the medical necessity was clear, but the "average" are hacks who rarely even review the paperwork because every question they ask was already covered in the documentation.

This has been my modal experience. Almost more of a procedural formality than a review of clinical necessity. That said (and as PsyDr alludes to below) I know their criteria and the language to meet the criteria, and they knew that I knew).