As a hospitalist, doing a peer to peer is a very important thing that adds to the deserved revenue to the hospital.
It is even more important with all the commercial insurance companies who have medical directors who deny inpatient status with every chance they can get.
Some reasons why Medical Directors of insurance companies deny inpatient status are
1. Lack of complete information about the patient: This is one of the easiest reasons that we can overturn for a denial. All that we need is to give them complete picture of the patient.
2. They have incentive to save money for their company. Unless, we know details of contract agreement and have experience doing peer to peer reviews, sometimes it gets difficult to overturn a denial.
3. Recurrent admissions with same medical problem: If you have patients with hepatic encephalopathy, hyponatremia, or Seizures with recurrent admissions, commercial insurances will combine as many of their admissions as possible. There is not much we can do to prevent those recurrent admissions and denials. Added to this list, COPD, CHF, Orthostatic hypotension, malignant pleural effusion etc will result in bundling of care denying payment to hospitals to hospitals.
There may be other reasons for denials. The insurance companies send the hospital a letter explaining why it was denied.
Whatever is the reason for a denial, it is always a good idea to do peer to peer for every possible patient. For each genuine inpatient stay that is denied, there is a potential loss of $1,500 to $9,000 for the hospital.
Some hospitals have physician advisors who do peer to peers. Some others ask regular rounding hospitalist to do the peer to peers.
What can we do to do an effective peer to peer review?
The first step is to know your patient well. For that one needs to prepare for 15-30 min for each case.
Never do a peer to peer without a minimum of 15 preparation.
Talk very nicely. Don’t argue. Just put forward your facts.
“List all the compelling reasons for the patient to stay inpatient for every day of hospitalization.”
Review complete chart of the patient incluiding lab results like severe electrolyte disturbances, worsening kidney function etc , failing outpatient treatment, results of imaging, clinical exam findings, hypoxia if present, abnormal vitals like hypotension, how much oxygen was the patient on each day, along with trends in these findings, and write them day by day on a paper so that when you present the case, you can put forward all this info without hesitation and delay.
The Medical Directors of insurance companies are very busy just as you are. It is more important for us than them to present all the facts thoroughly in the short time we talk to them to change their decision. So, have all the details in front of you collected on a piece of paper for ready reference.
If you keep doing peer to peer discussions, you will get more familiar with Inpatient criteria that medical directors from insurance companies know well.
Try to do as many P2Ps as possible to learn more. We can learn a lot from every P2P that we do. If you they deny again, ask them why they are denying if its not clear to you.
If the Medical Director talks about criteria only, you as a physician should bring up the point that checking the criteria is for utilization management nurses. For a physician, clinical judgement is more powerful factor in deciding to treat the patient as inpatient for the required duration.
Take a paper and write each day what happened to the patient starting from ER presentation to the discharge. Write everything that supports severity of illness and intensity of the treatment that was given.
Read nurses’ notes. Physicians’ Progress notes may not have all the information that can help overturn a denial. Review all the vitals. Hypotension or Hypoxia or tachycardia are simple but powerful vital signs that are in your favor to win the P2P review.
For a DKA patient, they may ask when the insulin drip was discontinued and when regular diet was started.
For a CHF patient, they may ask if the patient had hypotension [SBP less than 90], Hypoxia [sat less than 90%] or severe electrolyte disturbances or worsening Cr or recurrent tachycardia if patient has Afib history or if cardiology recommends to continue IV Diuretic even after more than 3 days of high dose IV Diuretic usage.
If a patient leaves AMA, make sure the physician documented all the steps that were taken to prevent a readmission. Two things most important in this aspect are 1. setting appropriate follow up appointments with family doctor and with specialists if necessary. 2. Document what the attending physician did and documented to explain the risks involved in patient’s signing AMA like septic shock or rehospitalization or including death and also document that patient understood and still left AMA despite knowing the risks.
Be very familiar with the EMR you use and it’s navigation to find quickly any details that they demand during your peer to peer review. For example, they can ask what procedure was done and on which day, what medication was given intravenously the last time etc. EPIC EMR software has a search function and you can easily find by searching.
For Medicare patients, the Physician Advisor can do utilization Management review and decide whether patient is meeting observation or inpatient criteria. They usually write a note in the chart about their decision. Most patients are inpatients if they stay more than 2 midnights.
For commercial insurance companies, from my experience, their Directors deny any case as inpatient unless the patient has a compelling reason for the patient to stay at least 48hrs after the admission order is placed by the admitting physician. The compelling reason does not have to be related to the the principal diagnosis. For example, I had a patient who was admitted with DKA which got completely better after 2 midnights but commercial insurance MD upheld denial until I told them that patient had a K of 2.5 with EKG changes compelling me to keep him through the third night at which time, case was approved.
Try to get access to clinical guidelines from Interqual or MCG. Your hospital should be able to provide the access.
“Never miss the chance to do the P2P appeal if you are new to the UM.“
Keep yourself relaxed. Make sure the area around you is not noisy while doing P2P appeal. Be nice to the person you are talking to. They are our peers and doing their jobs. Ask them how they are doing. Do not show anger or frustration if they continue to deny the appeal. Just continue to put forward any facts that you have gathered while you are preparing prior to beginning the appeal. Per Dr. Gaspere Geraci, “Being a calm, rational and a stable conversationalist who can make decisions and defend them” helps being a Physician advisor.
Usually, a lot of times, they don’t have complete information about the complete patient stay. So, ask them what they know or let them tell you why they denied and then try to fill in the blanks. Usually as soon as they get the required info, they will tell you if they approve the inpatient stay or not.
Using loud and harsh language is never a good way to get your case approved. They could record your conversation and you could potentially be reported to your medical board for unprofessional behavior. I am sure no one does that but it is good to know.
If denied again, they tell you that there is an option to do a formal appeal.
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