Nearly 10% of medical claims hospitals submit to payers are rejected or denied—translating to revenue loss of up to $5 million for the average hospital annually. Only 63% of denied claims are recoverable, and the administrative cost of following up on a claim denied by an insurer averages $188 per claim.
But medical claim denials often are avoidable. The insurance peer-to-peer review (P2P) is one important strategy used to avoid or reduce claim denials and therefore prevent revenue leakage.
According to one revenue cycle management company, hospital claim denials increased 23% in 2020. Nearly half of the denials were caused not by medical necessity (attributed to 6.6% of denials) but by administrative revenue cycle issues such as:
- Registration/eligibility (27%)
- Authorization/precertification (11.6%)
- Service not covered (10.6%)
What can healthcare organizations do if their requests for prior authorization are denied for lack of medical necessity or other reasons by an insurer? Physicians/provider organizations can request an insurance peer-to-peer review.
What is an insurance peer-to-peer (P2P) review?
This type of 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 peer review 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.
The insurance peer-to-peer 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 just 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.
Understand the types of claim denials that affect reimbursement
Most insurance peer-to-peer conversations focus on four types of denials:
Medical necessity
Cigna, one of the largest insurers, defines medical necessity as “health care services that a physician, exercising prudent clinical judgment, would provide to a patient. The service must be for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and in accordance with the generally accepted standards of medical practice.” In most cases, insurers don’t reimburse for treatments, prescriptions, or procedures that don’t meet their criteria for being medically necessary. If the clinical information provided doesn’t sufficiently support the need for a particular treatment, procedure, or course of action (e.g., inpatient status), the request for prior authorization—or the claim—will be denied.
Insurance companies and hospitals use specific, evidence-based criteria that the Centers for Medicare & Medicaid Services (CMS) or private companies (e.g., Interqual and Milliman) designed to determine whether a service, item, or inpatient stay is medically necessary. The criteria haven’t been designed to replace the professional opinions of providers, and physicians can ask for peer-to-peer reviews to help overturn medical necessity denials.
Timely notification
If the notification to authorize treatment was not received within the required period, the medical claim will be denied. For example, to comply with Aetna’s inpatient timely notification requirements, providers must notify the insurance company of hospital admissions within one business day. Failure to comply means that charges could be subject to a denial of up to $10,000.
Clinical validation
Payers conduct clinical validation audits to ensure that medical records validate the billed diagnoses and conditions. The payer may attempt to deny the validity of the principal or secondary diagnoses to downgrade the diagnostic related group (DRG) and lower the hospital’s reimbursement. For example, the auditor may determine that a diagnosis of pneumonia is invalid because the patient’s chest X-ray did not show evidence of pneumonia. The auditor might change a diagnosis to something else (such as bronchitis) or might completely remove the diagnosis with no replacement. In most cases, the denied diagnosis makes a difference in the DRG or the severity of illness (SOI)—usually a downgrade to a lesser SOI, or a DRG with a lesser relative weight than that of the billed DRG. This can reduce reimbursement.
Post-acute care
In this denial type, an insurer disputes the patient’s placement in a skilled nursing, long-term care, or inpatient rehabilitation facility, even though the physician recommends that the patient’s condition warrants it at the time of discharge.
Prep tips for an insurance peer-to-peer review
Identify the best advocate
The attending physician has firsthand knowledge of the details of the patient’s illness, but busy clinicians may not have enough time or reimbursement knowledge to prepare for and connect with the insurance company for the peer-to-peer conversation. A physician advisor who specializes in utilization review is familiar with the specific health plan contract and criteria and often has more time to devote to the conversation. However, some payers insist that the attending physician speak with their medical director.
The attending physician and physician advisor should collaborate to prepare for the insurance peer-to-peer review. The attending physician should document and fully inform the advisor about the patient’s condition. The advisor should build a strong case to support coverage and coach the attending physician on what to say.
Do your homework
Preparation for the P2P review is essential. At minimum, carefully review the following elements, which takes about 15-30 minutes:
- The adverse determination letter, which explains why the requested service was denied
- The documentation submitted with the procedure request. A request may be denied for insufficient information, so check whether the correct information was submitted.
- The payer’s medical coverage guidelines for the requested service. Refer to the insurance company’s website for coverage policies. Have those guidelines on hand to refer to during the call.
- The patient’s complete chart, including clinical exam notes, lab and imaging results, and abnormal vitals. Prepare talking points for the call.
- The details (e.g., what procedure/service was done on what date) as entered in the electronic health record system
- Evidence-based guidelines for the patient’s illness or condition. Use this information to assert that services should be authorized. For instance, you may state that according to pediatric asthma guidelines, a patient with a history of persistent difficult breathing, mental status changes, and who is receiving high-flow oxygen with frequent monitoring meets criteria for ICU-level care.
Six strategies to successfully navigate the peer-to-peer conversation
The insurance peer 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.
These strategies can improve the chances of a favorable peer-to-peer review outcome:
1. Schedule when there is flexibility with time
Schedule the phone call when you have a block of time available. The insurance company may give you a one-hour (or longer) window for the call. Specify your time zone to avoid scheduling confusion. Carry your phone and notes with you, so you don’t miss the call and lose by default.
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
Peer-to-peer reviews can be intimidating when you think the medical director’s mind is already made up. 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 peer-to-peer 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, you 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.
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