What is Peer to Peer?

Peer to Peer (or P2P) is essentially the patient’s doctor justifying a patient’s medical order, prescription, or inpatient status to the insurance company’s medical director. These interactions occur when the payer denies a claim according to their own internal policies and requirements. This is usually required within 72, 48, or even 24 hours from when the request was made. Otherwise, the claim will be denied.

While many of these peer to peer interactions occur due to denials for medical orders, services, and inpatient status, there are also instances for medications and devices. A doctor may speak with the medical director of a health plan to obtain a Prior Authorization (PA) approval or appeal a previously denied PA. Fifteen minutes of persuasive explanation of medical decisions from a physician may be more effective than weeks of processing a claim appeal.

Balancing Act

The process itself is tedious and time consuming. It can become a game of telephone with the insurance company’s medical director. Often the insurance company has all the information and documentation they need, but will still reach out to the patient’s physician to ask for further clarification. These interactions may end in failure to sway the medical director’s decision otherwise.

All the efforts in collecting the supporting documentation for a patient’s claim and debating current guidelines can be without success. When dealing with an unfavorable determination of inpatient status or medical order, there may be more success if time was redirected towards an appeal post-discharge. This would save the physician’s time and allow for more direct patient care.

The physician and supporting staff must weigh the benefits and challenges presented for each case. Sometimes, one method of acquiring approval may be more effective than the other.

Provider Preference

So why do some physicians prefer this method? Well, looking from the perspective of successful P2P cases, some physicians believe that P2P is easier. If done successfully, this overturn in the P2P process will prevent millions of dollars being tied up in the appeal process. Similarly, getting the approval through a peer to peer rather than through an appeal letter may make the world of a difference to patients. It can result in more timely access to treatment. Patients do not have to worry about being financially responsible for treatment if their insurance company denies the claim. In these cases, healthcare providers do not have to submit any additional medical records or information.

Due to the nature of P2P interactions, the insurance company’s physician and the patient’s physician are discuss on a higher level. Physician to physician. These conversations may go beyond the words on a patient charts and documents. The physician’s ability to communicate and connect with the medical director may be an important aspect to these types of approvals.

It has been noted that many insurance companies have directors in charge of specific regions of the country, so the physician may converse with the same select directors over time. This ongoing relationship is what some physicians attribute to their success in overturning denials.

Challenges

Although there are two physicians discussing the patient’s case in the Peer to Peer process, there can be challenges. The physicians on the payer side may not specialize in the area of medical practice that the claim is made for. This lack of specialization can hinder accurate determination.

Additionally, time is a major concern for physicians. Processing claims and subsequent denials takes approximately 14.4 hours of a physician’s practice time each week. Many health systems today have separate roles to review these denials and participate in P2Ps so that the patient-facing physicians do not have to use their time to do administrative tasks.

Two Sides to Every Coin

To put it simply, there are always two sides to a coin as there will always be two sides to this process. While some physicians consider it to be a time-consuming chore, some other physicians consider it to be a golden opportunity. With hardly any statistical data to support one side or the other, collecting information on what physicians prefer and the total expenses involved in a peer to peer versus an appeal would be helpful to shed more light on this process.

References

Hassaballa, D. H. (2019, January 23). The Pain (and Joy) of the Peer-to-Peer Conversation. Retrieved June 26, 2020, from https://medium.com/@drhassaballa/the-pain-and-joy-of-the-peer-to-peer-conversation-f57b98fa6d6a

Juliet B. Ugarte Hopkins, M. (2018, April 11). Are Peer-To-Peers Worth It? Physician Reaction. Retrieved June 26, 2020, from https://www.racmonitor.com/are-peer-to-peers-worth-it-physician-reaction

Juliet B. Ugarte Hopkins, M. (2018, February 14). Are Peer-to-Peers Worth the Effort? Retrieved June 26, 2020, from https://www.racmonitor.com/are-peer-to-peers-worth-the-effort#:~:text=P2P is an opportunity for,why inpatient status is appropriate.&text=If not, the attending physician,decide what to do next.

Make ‘Peer-to-Peer’ Happen Within 24 Hours, Or Face Denied Claim. (2018, January 1). Retrieved June 26, 2020, from https://www.reliasmedia.com/articles/141921-make-peer-to-peer-happen-within-24-hours-or-face-denied-claim

O’Reilly, K. B. (2019, November 01). 8 prior authorization terms that drive every doctor crazy. Retrieved July 08, 2020, from https://www.ama-assn.org/practice-management/sustainability/8-prior-authorization-terms-drive-every-doctor-crazy