February 15, 2018

Are Peer-to-Peers Worth the Effort?

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An analysis of your peer-to-peer process might lead to your abandoning the program.

The peer-to-peer (P2P) process is a particularly abhorrent chore for physicians. These phone conversations are generally offered by commercial and managed insurance plans when their clinical case manager or medical director does not feel that inpatient status is supported for a particular patient. P2P is an opportunity for the attending physician (or sometimes, the consulting physician) caring for the patient to verbally duke it out with the insurance plan’s medical director about why inpatient status is appropriate.  

The attending physician will either convince the medical director that inpatient status is appropriate, or not. If not, the attending physician, with help of the case manager, must decide what to do next. Ideally, the hospital’s physician advisor has already weighed in on the appropriate status and the attending physician has been made aware of his or her opinion by the case manager (if not the physician advisor herself.) If both the physician advisor and the attending physician agree that inpatient status is appropriate, the designation should stand despite the determination by the insurance medical director that outpatient status with observation services is appropriate. In such a case, the hospital’s denials and appeals team will pursue an appeal if a medical necessity denial comes down the pike following patient discharge.  

The P2P process itself is tedious and time-consuming. The insurance plan’s case manager calls the patient’s case manager, the case manager contacts the attending physician, and finally, the attending physician calls the medical director.

Usually, this game of telephone tag is required to be completed in 72, 48, or even 24 hours, depending on contractual rules. Many times the “conversation” between physicians involves pointless debates over MCG or Interqual guidelines. Other times, even if the clinical evidence illustrating the severity of the patient’s symptoms and complexity of their plan of care is rock-solid, there is no swaying the medical director. So, why conduct P2Ps? 

It’s a good question.

The common understanding is that it’s easier to overturn a denial for inpatient status with a P2P than it is with the appeal letter process post-discharge. But is this really the case? If you are not tracking your P2Ps and their outcomes, how can you know? This is why you need to monitor this metric. How many P2Ps are being performed by your physicians versus your physician advisor(s)? What percentage of each actually results in the insurance plan supporting inpatient status?

If the attending physicians’ P2Ps result in only 20 percent being overturned, and your physician advisors hang up the phone with an overturn 80 percent of the time, why the heck aren’t your physician advisors participating in all of the P2Ps? Perhaps they are not allowed to, contractually, per the insurance plans, but you should make sure.  

What’s happening per payer? Are your physicians/physician advisors generally successful with one plan, but almost never with another? You won’t know unless you check out the data! Maybe it’s worth continuing P2Ps with the one, but scrapping them for the other.

If, no matter who participates in the P2P, only a small percentage of the cases are overturned, consider a radical thought: abandoning P2Ps altogether. Granted, this plan hinges entirely on whether or not your contracts allow appeal post-discharge without a P2P beforehand. But if they don’t, it’s time for some soul-searching.

Why are multiple individuals across your hospital expending time and energy into a process that infrequently leads to a positive outcome, but always leads to even more time and energy focused into an appeal? Why not just ditch the generally fruitless efforts on the front end and concentrate on the post-discharge appeals?  

Check out your stats and consider these points. Prepare yourself for the very real possibility that no one in your hospital is the wiser when it comes to the effectiveness of the P2Ps. If not…add another project to your list!

Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADV

Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADV, is a physician advisor for case management, utilization, and clinical documentation at ProHealth Care, Inc. in Wisconsin. Dr. Ugarte Hopkins practiced as a pediatric hospitalist for a decade. She was also medical director of pediatric hospital medicine and vice chair of pediatrics in Northern Illinois before transitioning into her current role. She is the first physician board member for the Wisconsin chapter of the American Case Management Association (ACMA), a member of the RACmonitor editorial board, and a member of the board of directors for the American College of Physician Advisors (ACPA). Dr. Ugarte Hopkins also makes frequent appearances on Monitor Mondays.

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