As a Physician Advisor working for the hospital, doing a peer to peer is a very important part of my job that adds the deserved revenue to the hospital.
When I start my work at 7am, I start getting text after text from the UN nurses with denials from commercial payers. I quickly review the charts and request for P2P reviews.
Immediately, I start preparing for P2P. First, I go all the way to History and Physical [H&P] and read it. Then keep going up one note after another gathering all the points that can contribute to supporting inpatient status. By the time I am done reading the most recent note, I get a fairly good idea if the patient’s clinical indicators actually support Inpatient status or not.
Then I review the vitals, lab results and notes from nurses, physical therapy etc. I go to medication list check what all iv meds patient received during the hospital stay. I make sure to count the number of each iv-medication given on each day and note it all down.
Some reasons why Medical Directors of insurance companies deny inpatient status are
1. Lack of complete information about the patient: This is one of the easiest reasons that we can overturn for a denial. All that we need is to give them complete picture of the patient and medical directors from commercial payers approve Inpatient status.
2. The Medical Directors from commercial payers have the incentive to save money for their company. Unless, we know details of denial letter and have experience doing peer to peer reviews, sometimes it gets difficult to overturn a denial. Always, read the denial letter which lists all the clinical indicators which can help to approve IP status.
3. Recurrent admissions with same medical problem: If you have patients with hepatic encephalopathy, hyponatremia, or Seizures with recurrent admissions, commercial insurances will combine as many of their admissions as possible. There is not much we can do to prevent those recurrent admissions and denials as these denials are according to the contract. Added to this list, COPD, CHF, Orthostatic hypotension, malignant pleural effusion etc will result in bundling of care denying payment to hospitals.
Whatever is the reason for a denial, it is always a good idea to do peer to peer for every possible patient. For each genuine inpatient stay that is denied, there is a potential loss of $1,500 to $9,000 for the hospital.
Some hospitals have physician advisors who do peer to peers. Some others ask regular rounding hospitalists/attendings to do the peer to peers.
What can we do to do an effective peer to peer review?
The first step is to know your patient well. For that one needs to prepare for 15-30 min for each case.
Never do a peer to peer without a minimum of 15 preparation.
Talk very nicely. Just put forward your facts.
“Key: List all the compelling reasons for the patient to stay inpatient for every day of hospitalization.”
Review complete chart of the patient including lab results like severe electrolyte disturbances, worsening kidney function etc , failing outpatient treatment, results of imaging, clinical exam findings, hypoxia if present, abnormal vitals like hypotension, how much oxygen was the patient on each day, along with trends in these findings, and write them day by day on a paper so that when you present the case, you can put forward all this info without hesitation and delay.
The Medical Directors of insurance companies are very busy just as you are. It is more important for us than them to present all the facts thoroughly in the short time we talk to them to change their decision. So, have all the details in front of you collected on a piece of paper for ready reference.
If you keep doing peer to peer discussions, you will get more familiar with Inpatient criteria that medical directors from insurance companies know well.
Try to do as many P2Ps as possible to learn more. We can learn a lot from every P2P that we do. If you they deny again, ask them politely why they are denying if its not clear to you.
If the Medical Director talks about criteria only, you as a physician should bring up the point that checking the criteria is for utilization management nurses. For a physician, clinical judgement is more powerful factor in deciding to treat the patient as inpatient for the required duration.
For a DKA patient, they may ask when the insulin drip was discontinued and when regular diet was started.
For a CHF patient, they may ask if the patient had hypotension [SBP less than 90], Hypoxia [sat less than 90%] or severe electrolyte disturbances or worsening Cr or recurrent tachycardia if patient has Afib history or if cardiology recommends to continue IV Diuretic even after second Midnight.
If a patient leaves AMA, make sure the physician documented all the steps that were taken to prevent a readmission. Two things most important in this aspect are 1. setting appropriate follow up appointments with family doctor and with specialists if necessary. 2. Document what the attending physician did and documented to explain the risks involved in patient’s signing AMA like septic shock or rehospitalization or including death and also document that patient understood and still left AMA despite knowing the risks.
Get very familiar with the EMR you use and it’s navigation to find quickly any details that they demand during your peer-to-peer review. For example, they can ask what procedure was done and on which day, what medication was given intravenously the last time etc. Some EMRs like EPIC has a search function, and you can easily find by searching.
For Medicare patients, the Physician Advisor can do utilization Management review and decide whether patient is meeting observation or inpatient criteria. We should write a note in the chart about the decision. Most patients are inpatients if they stay more than 2 midnights.
One time a Medical Director told me that if patient has hypokalemia and has upto 6 PVCs per min, then Inpatient status can be approved.
Try to get access to clinical guidelines from InterQual or MCG. Your hospital should be able to provide the access.
“Never miss the chance to do the P2P review if you are new to the UM. You will learn a lot”
Keep yourself very relaxed. Make sure the area around you is not noisy while doing P2P review. Be nice to the person you are talking to. They are our peers and doing their jobs. Ask them how they are doing. Do not show anger or frustration if they continue to uphold the denial.
Using loud and harsh language is never a good way to get your case approved. I made a lot of friends with medical directors from insurance companies as I work for our hospital.
If denied again, they tell you that there is an option to do a formal appeal.