Suggestions for conducting peer-to-peer appeals for denials If you are wondering why you should read this if you think you are not a rebeginner, well, it is because you actually are one. Beginnings do not disappear, they just reproduce. Novices are just starting, veterans have started over and over. We…
Once a denial is issued, a P2P will no longer be an option. An astute physician advisor recently brought to my attention a change to the Humana Medicare Advantage peer-to-peer (P2P) process. The announcement (which can be found at this link: https://www.humana.com/provider/support/publications/your-practice-newsletter/peer-review-process-changes) states that effective Aug. 1, a P2P with…
Educate physicians on information that is relevant to prove medical necessity. One of the most common requests our physician advisors receive from hospitals is to review appropriate status assignment and determination of medical necessity. When the insurance company disagrees with a status, a denial is generated, often creating an opportunity…
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…