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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Photo by Quino Al on Unsplash

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:

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.

Written by

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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