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Updated: July 25, 2022
By Jordan P. Roberts, PA-C

Peer to Peer & Utilization Review

Utilization Review Peer to Peer

If you are struggling with insurance denials and need to learn how to win peer to peer utilization review cases, we're here to help. Most experienced clinicians have had to deal with this from time to time, and many have a winning strategy that works for them.

Arm Wrestling for Peer to Peer or Utilization Review Approvals?

If you are struggling with insurance denials and need to learn how to win peer to peer utilization review cases, we're here to help. Most experienced clinicians have had to deal with this from time to time, and most have a winning strategy that works for them.

Whatever your personal feelings are about this process, ignoring it won't make it go away. Insurance companies really do need good utilization review departments. That means denials, peer-to-peer phone calls, and paperwork are not going anywhere.

However, there are ways to minimize your own burden despite increasing regulation and restriction in healthcare. If you do find yourself on the wrong end of these phone calls more often than you'd like, then read on.

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Clinical Documentation Review and Clinician Advisors

Even if the term clinical documentation improvement is new to you and you've never met a Clinician Advisor, there's a good chance they know you. Clinician Advisors work in a variety of settings, from the clinical institution to the corporate insurance firm.

Healthcare institutions who felt burned by payers needed a way to fight back. Payers who felt burned by overuse of the healthcare system needed a way to remain solvent. Thus, a new role for clinical experts was formed, and they called it Clinician Advisor

Editorial note: you may have heard the term Physician Advisor before. However, Clinician Adviser is also used; in my opinion, this is more accurate for two reasons. First, they ‘advise' more types of healthcare professional than one (think NP's, PA's, CRNA's, and any other billing clinician). Second, a variety of clinician type can hold this role, including the above mentioned professionals. 

Here's a look at one part of that world that you almost certainly experienced.

When it comes to utilization review (UR), especially the peer-to-peer phone call, there are two types of people in the clinical world. Those who win the review, and those who don't. If you aren't happy with the decisions you are getting, this article is for you. 

We'll first explore some possible ways to overcome a medical necessity denial. We'll also provide resources to help with clinical documentation improvement that you can use to save time and energy.

The Denial

If you've already gotten the denial, you'll have to act. However, there is good news. When clinicians appeal these decisions, they win most of them. In this article, we'll show you how some of them do it and how you can avoid it.

1. Respond Quickly

These denial letters are usually time-dependent. They might say you have thirty days to initiate an appeal or they might say you have 48 hours. That’s 48 hours from the date they sent it, which is usually yesterday. 

Once that window closes, you have lost a lot of leverage to change the outcome of the decision. 

2. Build Your Case Ahead of Time

No matter how nice the clinician on the other end of the line is, never forget this is a (professional) debate. However, you have home court advantage. Even if you don’t remember all the specifics about the case, you probably still know more than your counterpart on the other end of the line. They are are likely reviewing the case for the first time when you call.

Your first goal is to find out more about why the order was denied. Hopefully you've determined this prior to the phone call. With this information, you can anticipate and overcome the reviewer’s objections. You’ll need more than the letter's boilerplate explanation, which might not have all the information you need.

Remember that you are also an expert in this case. The initial denial was probably made by someone matching your documentation to their checklist of guidelines for the ICD-10 code you entered.

In fact, a report by the Department of Health and Human Services a few years ago found that denials occurred because of a true lack of medical appropriateness in only a minority of cases. That's a polite way of saying we probably don't document well enough most of the time this happens.

3. Be Sure of Yourself

Clinicians often have a need to be more right than one another. It’s natural to want to try to overpower your poor reviewer until they give in. Some of them may even be tempted to do that to you.

But since they don’t own the insurance company, they need a reason to reverse the original decision. Trying to intimidate someone three states away is less effective than providing objective medical evidence.

That said, you need to be firm but professional in your tone and confident in your reasoning when discussing the case.

4. Document Like the Lawyers Are Watching

If the claim is still denied after your efforts, you may understandably feel frustrated. Avoid the temptation to preemptively blame someone else for any potential bad outcome that could be perceived as a result of this decision.

Strictly speaking, the insurance company is more likely to be liable for a breach of contract rather than medical negligence for incorrectly denies claims. That's not to say there isn't precedent for utilization review medical directors facing ‘bad faith’ denial claims or additional liability. However, this is probably the rare exception for this to occur.

However, if the case is still denied for any reason, you need to protect yourself and ensure your patient is getting appropriate care. The best way to do this is to document everything you can about the interaction. And do it immediately, because if you didn’t write it, you didn’t do it. Be sure the name of the medical director is clear to anyone else who reads the chart. It's a good idea to also let the patient know how things went. 

Include your medical reasoning their counter-reasoning, guidelines for approval, and any other pertinent information.

Here's a great lesson on why documentation is so key to your own protection, as well as good patient care.

5. Improve Your Clinical Documentation

One way to improve your clinical documentation is to practice different kinds of writing. Medical writing is very different from what you write in the medical record, but can also make you a better clinician.

However, clinical documentation improvement has just about become its own specialty in medicine. A relatively new, but high-paying job born from this field is the physician advisor. If you have the skills and documentation knowledge, we see no reason other clinicians won't be valuable members of this team. 

For a more in-depth look into the world of clinical documentation improvement, consider this guide. It is useful for just about any clinician who is unsure of their own documentation skills. Or for those who want to improve their peer to peer or utilization review success rate.

However, anyone who knows they have areas where they want to improve can also benefit from it.

First Published: January 29, 2018

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