The Pain (and Joy) of the Peer-to-Peer Conversation

They will always be a part of healthcare. Here are some tips to make them better…maybe even enjoyable.

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Back in my private practice Pulmonology days, I would frequently see a patient in the office — who has been smoking for decades — with a pulmonary nodule (spot on the lung). Fearing that this may be a cancer, I would then order a CT scan to better characterize the finding.

Not long after, I would get a phone call from one of my nurses in the office: “Hi Dr. Hassaballa. You need to do a Peer-to-Peer to get the CT approved.” I would growl with frustration.

A “Peer-to-Peer” discussion is a phone conversation with an insurance company Medical Director. I would have to describe to this physician why I am ordering the CT scan, and then he or she would either approve or deny the request.

So, I would dial into a phone number, follow a few prompts, and then speak with said Medical Director about how I am worried that this spot was a cancer, and I need a CT scan to better characterize it. I would always “win,” meaning I would get approval for the CT scan. Still, it would annoy me to no end that I would have to jump through this irritating hoop.

Fast forward to today, and I am doing a different type of Peer-to-Peer (P2P) call: speaking to an insurance company Medical Director and discussing why a hospital stay needed to be at the inpatient level of care. I do this on behalf of hospital partners as a Physician Advisor.

First things first: like it or not, they are here to stay. Insurance payers are not going away, and they will — from time to time — deny inpatient stays alleging a “lack of medical necessity.” Get used to it…it is the way of the world (for now, at least).

Still, that doesn’t mean it has to be a painful experience (although many times it can be). I have done dozens upon dozens of P2P calls, even completing 18 in one week! They can be a pain-free experience, fun even. And there is a good chance that you, dear reader, may be asked to complete one of these conversations. If that opportunity presents itself, I have found these tips to be helpful:

  1. Be respectful. These are physicians like us. Just like us, they have gone through years of training, and many — if not all — have been in practice before. Some are even currently practicing and do this on the side. I like to begin the calls with some niceties: “How are you?” or “Happy New Year,” at this time of year. This is always good life advice in general, and in the setting of a P2P, it can go a long way in making the call much go much more smoothly.
  2. Take the emotion out of it. This is easier when the person doing the P2P is a Physician Advisor, like me, who is removed from the case itself. That said, many times, the insurance company insists that the treating physician be the one to have the P2P. As a result, when on the phone with the Medical Director, try to be as calm as possible, and do not take the phone call personally.
  3. Always ask what information the Medical Director has. Many times, the insurance company has incomplete information, and based on this incomplete picture, they will issue the denial. Ask the physician what information they have. I always begin the conversation that way. Many times, they don’t know that the patient was later intubated and is now in the ICU on vasopressors. Other times, however, they have all the information about the case. You will not know unless you ask.
  4. Familiarize yourself with evidence-based guidelines. Although it may seem so, the payer Medical Director does not arbitrarily issue a denial for lack of medical necessity. There is a clinical basis for the denial, and it is based on usually one of two evidence based guidelines: Milliman Care Guidelines (MCG) or Interqual. Almost every hospital has access to one of these guidelines. So, ask the Case Manager to show you the guidelines, either MCG or Interqual, for the diagnosis that was denied. That way, when conducting the call, you can understand from where the Medical Director is coming and maybe even use the guidelines to further bolster your arguments for medical necessity.
  5. Stand your ground…with respect. It is easy when the Medical Director on the other line doesn’t know that the patient is still hospitalized and is in shock. There are many times, however, when the Medical Director is intimately familiar with the case in question. If you believe, in your heart of hearts, that the case should have been an inpatient, then calmly and dispassionately state your case and do not back down. Many times, these cases are in the gray zone — where reasonable people can disagree over the level of care. Have a discussion with the Medical Director, not a shouting match.
  6. If the documentation is poor, prepare to have a hard time. When reviewing charts, I want to trust the treating physician or APP. I wasn’t there, and I did not see the patient face-to-face. I trust that the clinician believed this patient was sick enough to be admitted to the hospital as an inpatient. That said, if the documentation does not reflect this thought process, then there is very little on which the clinician or Physician Advisor can stand to argue for medical necessity. You do no one a favor by leaving scant documentation, and poor documentation makes justifying medical necessity exceedingly difficult.
  7. Sometimes, you will lose. It is always nice to “win” a P2P call. That said, there are going to be many times where the Medical Director is unmoved by your argument — however cogent and correct — and will uphold the denial. Almost always, they will say, “The facility has a right to a written appeal, where the entire chart will be examined, and another Medical Director will look at the case.” It is going to happen, and it is not worth getting all hot and bothered about it. Go ahead and pursue the written appeal (I will post about this very soon).

It is understandable that these P2P calls can be annoying, and they seem to be a needless “hoop” through which insurance companies make doctors, nurses, PAs, and hospitals jump. They really are not. In this day and age, like it or not, we can’t just admit patients to the hospital because we feel like it.

There has to be some clinical basis — other than your “eminence-based medicine” — for the admission. If the case is not clear, and you don’t document properly, prepare for the case to be denied. And if the opportunity presents itself to do a P2P, don’t pass it up. It can be a very educational and, dare I say it, enjoyable experience.

The opinions expressed in this post are my own and do not reflect those of my employer or the organizations with which I am affiliated.

NY Times featured Pulmonary and Critical Care Specialist | Physician Leader | Author and Blogger | His latest book is “Code Blue,” a medical thriller.

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