Not all P2Ps should be pursued.
In my reporting a few weeks ago, I encouraged physician advisors and other leaders in case management to analyze the outcomes of their peer-to-peers (P2Ps). As a reminder, P2P conversations revolve around the appropriateness of Inpatient status and take place between the medical director of an insurance plan and either the attending physician for the patient or a physician advisor.
My main recommendation about P2Ps is to be aware of what’s happening in your shop. Are only attending physicians participating? Only physician advisors? Both? What are each group’s stats when it comes to overturns? Are your physician advisors much more successful than the attendings? Perhaps you’ll want to remove the attendings from the mix. What are the stats per payer? Does one in particular rarely overturn a denial when the others are more balanced?
The thought of abandoning P2Ps altogether was felt to be too drastic for a number of physician advisors who wrote in after reading my original article. The daily workload for Mark Safalow, MD, regional vice physician advisor for Prospect Medical Holdings, covering Waterbury Hospital and Eastern Connecticut Health Network in Connecticut, and East Orange General Hospital in New Jersey, involves reviewing denials, participating in P2Ps, and assisting with the creation of second-level appeal letters. Prior to joining the hospitals he now covers, the hospitalists completed the P2Ps but only when they had the time or inclination to do so. This is a common problem faced by hospitals that rely on their hospitalists or other attendings. Not only do the practicing clinicians wish to concentrate on patient care, they also usually have little desire to learn how to rebut arguments about MCG and Interqual criteria (which, as we know, should not even come into the equation when it comes to a physician-to-physician conversation about the medical care of the patient).
Another common point was the success physician advisors can have in overturning denials through sheer collegiality and rapport with insurance medical directors. Plans commonly have directors assigned to specific regions of the country. So it is not unusual for a physician advisor to speak with the same handful of individuals time and time again. Many respondents reported that this familiarity becomes invaluable when it comes to overturning denials.
Usually, it’s felt that P2Ps save time in overturning denials for medical necessity on the front end, while the patient is still hospitalized. When a P2P results in the insurance plan’s medical director upholding the denial for Inpatient status, the next step for the hospital is to write an appeal letter once the official denial is issued after the patient is discharged. This can result in delayed payment for weeks, if not months. Dr. Jeffrey Pilger, physician advisor for care coordination and utilization management at St. Elizabeth Healthcare in Kentucky, emphasized that overturning denials in the P2P process and preventing millions of dollars being tied up in the appeal process post-discharge makes a big difference to the C-suite.
Another important issue to consider is that not all P2Ps should be pursued. While these should be few and far between, there sometimes will be cases where Inpatient status is simply not appropriate and therefore, not defensible. Daniel Zirkman, MD, chief physician advisor at CarolinaEast Health System in North Carolina, wrote, “The cases I chose not to appeal were because I did not believe they were [Inpatient] appropriate to begin with, and certainly lacked documentation to support an [Inpatient] status.”
While the knee-jerk reaction might be to proceed with every P2P as it comes down the pike, it’s important to take a critical look at each case. Per Dr. Pilger, “some peer-to-peers…should never take place because…the denial is appropriate…choosing your battles is half the battle when it comes to denials.”
Clearly, effectively pursued and managed P2Ps can make a positive financial impact on your health system. I continue to encourage you to investigate your own processes and outcomes and see where you have opportunity to improve.