What is the "Peer-to-Peer call" ("P2P") ?

By Martine G. Brousse (not AI!)

"The Medical Bill Whisperer"

Patient Advocate, Certified Mediator

AdvimedPro

September 12, 2024

The "Peer to Peer" process is one of the most important tools at insurance companies' members' disposal to "convince" the Utilization Management department to approve a service/procedure/device/Rx/treatment.

This is NOT to dispute claims already processed, but in order to obtain an authorization and guarantee of coverage/payment previously denied.

Let's see what this P2P process is, why it's important to you, and how to facilitate the best outcome.

A. What is this "Peer to Peer"

1. It is the phone conversation between your referring/treating/prescribing/supervising physician and your insurance company's medical director following your insurance’s denial of an authorization request for a treatment, surgery, procedure, device or Rx.

These denials can use reasons such as :

• "lack of medical necessity" : clinical justification was not enough or not provided

• "experimental or investigational": the procedure or prescribed treatment are not FDA-approved, not considered safe and effective, not usually prescribed for this diagnosis, are declared "standard of care" in the US

• "not covered per medical policy": the insurance's medical policy does not include the diagnosis, or the medical condition does not meet the standards required by that policy

• "Excluded": the procedure or diagnosis are specifically listed as not payable and not covered by the policy. Examples can include cosmetic surgery, dental services under the medical policy, compounded Rx, acupuncture, wilderness therapy etc

2. It is the opportunity for your Dr to explain to the insurance's medical director the specific and timely need for the service/procedure/device/Rx and to clarify the rationale of the medical decision that clinical records cannot convey.

3. It is also the opportunity for your Dr to present additional clinical information, records, documentation to support and justify the level of intervention and treatment plan, and why

this is the only or best option for you to regain your health, maintain your current status, slow disease progression or as a last resort to prolong life or quality of life.

4. This is also the opportunity for the insurance’s Medical Director to review and overturn their original decision based on this new info and to issue/expedite an approval.

B. What does it mean for you?

• if the insurance's Medical Director overturns the original denial, it means that you can have that surgery/treatment/device/Rx/protocol and that it will be covered - and therefore payable - by your plan. The insurance will guarantee that claims relating to it will be processed and accepted, and paid according to the terms of your policy, and whether your out of pocket liability has been met.

• it also means you gain time, as P2P calls are usually scheduled within a week of a denial, and a response by the insurance's Medical Director can be extremely quick, if not happen during the call

• it means you avoid the need of filing an appeal, which is a written request for a reconsideration. This process would take a good week at best - if your situation is extremely urgent or life-threatening - and up to 30 to 60 days otherwise

• it means you have greater chances of success. An appeal is handled by a reviewer, not a Medical Director, and often will lead to a negative decision, as a non-medical reviewer will usually never overturn a MD's decision, even if they had more than 5 min on average to review medical records and rule on medical matters they have little training on.

• while a review by an "external impartial reviewer" is a right available to insurance members, is usually only happen at the second degree appeal level, meaning several weeks down the line. In many cases, that external reviewer may be someone hired and paid for by the insurance, begging the question of impartiality.

C. Improve your chances

1. Make sure the right physician requests it. Only the referring physician can request that P2P call. Even if another medical professional will ultimately render the service, it is only the physician who requested the (now denied) authorization who has the right - and duty - to proceed.

   
   

2. Not all medical professionals are equal. It is unfortunate that insurances' Medical Directors can - and do - dictate who they accept as a "peer" for this call. In my experience, accepted are: MDs, DOs, Ph.Ds or Psy.Ds. Sometimes accepted are prescribing Nurse Practitioners, Physician Assistants, Doctors of Naturopathy, Licensed marriage and family therapists, Marriage and Family therapists, licensed clinical social workers or master of social work. Never accepted are those who will provide the service but cannot or did not order it: Speech Therapists, Occupational Therapists, Physical Therapists, ABA Therapists, facilities, infusion centers, home health agencies etc ...

   
   

3. Patients or members have no right to a Peer to Peer, or even to listen on it, even if you are a MD or the best person to know your situation. Sorry, I'm not making the rules. If your Doctor cannot explain themselves and their decision, then I would personally have questions. The insurance's Medical Director certainly would have little choice but uphold the initial denial. And if you self-procured the services, forget about requesting this call. You would still need a physician to order them and therefore defend their need.

   
   

4. Timeliness is important The time constraint to request a peer to peer call is indicated on the rejection/denial letter issued by the Utilization Management Dept. A call usually gets scheduled within 5 days from a request by the ordering physician. some insurances allow a couple of weeks to file a request, others a couple of days.

   
   

5. Prep and documentation are a must The office of the referring/prescribing physician should send any additional clinical documentation or supportive evidence to the Medical Director ahead of the scheduled call, to allow the opportunity for a review and better discussion. Keeping documentation precise, concise and to the point usually leads to the best results.

While Peer to Peer calls are out of the hands of patients, they should know about that option and should ask - or pressure if needs be - any referring or prescribing physician to undertake one in case of a denied authorization.

Not only does their health depend on it, but crushing financial consequences can be avoided as well.

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Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.

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@martine brousse 2024 @ the medical bill whisperer 2024