Hospitals and health systems spend an estimated $19.7 billion per year to fight denied claims, according to a recent report. But medical claim denials are often avoidable. The insurance peer-to-peer review (P2P) is one important strategy used to avoid or reduce claim denials, and therefore, prevent revenue leakage.
What can healthcare providers do if their requests for prior authorization are denied for lack of medical necessity or other reasons by an insurer? Physicians can request an insurance P2P.
What is an insurance P2P review?
An insurance P2P review is not to be confused with clinical or medical peer review. During medical peer review, physicians and advanced practice professionals (APPs) evaluate the quality of their colleagues’ work for both punitive and non-punitive review to meet or exceed prevailing standards of care and to self-improve.
An insurance P2P review, on the other hand, is a type of appeals process that occurs by request after a payer denies a request for services. The denials often are made for medical orders, services, and inpatient status but may also be for medications or medical devices.
How does an insurance P2P review work?
The insurance P2P review is a scheduled phone conversation during which an ordering physician discusses the need for a procedure or drug with the insurance company’s medical director to obtain a prior authorization approval or appeal a previously denied prior authorization.
This phone conversation typically lasts five to ten minutes and is usually required within 72, 48, or even 24 hours from when the request was made. Otherwise, the case will be closed, and the claim denied.
How can physicians successfully navigate an insurance P2P review?
The insurance P2P review process is time consuming and tedious, often involving back-and-forth messages left for a payer’s medical director. Physicians may be put on hold, even when they call at the designated time. If a physician cannot wait 30 minutes to conduct the review, the case may be closed.
Six strategies to successfully conduct an insurance P2P review
These strategies can improve the chances of a favorable P2P insurance review outcome:
1. Prepare for the conversation
Set clear goals and have a specific goal for the review (i.e. approval of a certain procedure or medication) and focus on why it is the best option for the patient. Engage the insurance physician with clear, objective clinical evidence and focus on how the treatment meets established standards of care.
2. Concisely state your case
Be succinct and provide objective facts from the clinical notes. Consider that the payer may not have complete information about the patient’s symptoms, test results, and care. Ask the payer’s medical director what they know about the patient or ask them why they denied your request for services. Then try to fill in the blanks. You may need to provide additional documentation after the call to support the case.
3. Build rapport and be respectful from the start
Building a friendly rapport can be difficult when time is short and the stakes are high. However, begin the call with a brief, informal greeting to establish a non-combative dynamic and level of trust. It will go a long way toward laying the foundation for a mutually respectful conversation.
4. Stay positive throughout the call
P2P reviews can be intimidating when you think the medical director’s mind is already made up. Approach the review as a collaborative discussion rather than a debate. Try to understand the medical director’s agenda, remain respectful, and remember that it’s not personal even if you lose a very solid case.
5. Maintain a clinical lens
Appeal to the reviewer’s medical professionalism, especially if the payer is denying coverage based on a narrow interpretation of the guidelines for a very ill patient with a complex disease. Describe the patient’s condition and bedside interactions with you and other clinicians. You might ask, “Given these circumstances, where else—or how else—could we have safely cared for this patient?”
6. Remind the medical director of the provider/payer partnership
The insurance P2P review is your opportunity to advocate for your patient—who is also the insurance company’s member. Medical directors may interrupt you or rush through important clinical details. Politely and respectfully remind them that the case merits a well-structured call with a complete review to cooperatively service their member.
By thoroughly preparing for the insurance peer-to-peer review and following these strategies, healthcare providers can obtain prior authorization approval or successfully reverse denied authorization so the services your patient needs are covered. This benefits the patient and your health system’s bottom line.
