Excerpted from SEAK’s course, “How to Start, Build, and Run a Successful Disability and File Review Practice”
Hi everyone. I’m Dr. Julia Kinder. In this section, we are going to discuss the peer-to-peer call. So what is the peer-to-peer call? Let’s discuss the basics. It is simply a discussion with a provider about a health benefit that was denied. Some peer-to-peer calls are very quick, a minute or two, and very easy. Some are intellectually challenging and more time-consuming.
The rare case can be very difficult due to the situation on the other end of the phone, but we will talk more about that later. You will have reviewed and denied a service such as an in-patient hospitalization, or a benefit such as a hospital bed. The ordering provider can then request a discussion with you about the denial. The provider could be a physician of the same specialty, a physician of a different specialty, a nurse practitioner, a therapist, or with a doctor whose job it is to do peer-to-peer calls. Hospitals often hire doctors to do all of their peer-to-peer calls.
The company that you work for will determine rules for which providers can request a peer-to-peer. Some companies, for example, will not allow a peer-to-peer with a doctor who did not actually take care of the patient. You will get a notice that a peer-to-peer has been scheduled, typically by email. Some companies schedule the peer-to-peer calls for you. Some will allow you to decide when you would like to make that call.
There is usually a specified timeframe within which the call must be completed. These rules are set by companies, but there are also state and federal regulations that dictate the timeframe within which a final decision must be made. You will also be told how many attempts you must make. Three attempts to call out is typical. When you don’t reach a provider on an attempt, be sure to document your try and what happened. Was there no answer? Were you placed on hold for a long time? Did you leave a message? And any other pertinent details.
Most of my time for a peer-to-peer call is actually spent before the actual call. Before the call, you would need to thoroughly review the following things. The reason that it was denied, of course, the denial rationale that the provider read. It is important to see exactly what the provider saw. Denial rationales are written in a more simplistic way than the policy. I have found sometimes that the denial rationale sent to the provider may need further explanation and details about the policy itself. Often, the provider simply didn’t understand why it was denied.
Once you further explain, the provider may agree with you at that point. You also need to review the full criteria. There may be criteria points beyond the denial, which must be addressed. For example, a drug may have been denied for a non-FDA-approved diagnosis. Oftentimes, the diagnosis simply isn’t submitted, but on the call, the provider may say, “Yes, the member actually does have an FDA-approved diagnosis.” So that criteria bullet point is met. You then have to go to the next question in the decision tree orally with the provider.