By: Michael A. Salvatore, MD FACP CHCQM, Physician Advisor
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 all begin as beginners and then we begin rebeginning.
So as a perpetual rebeginner, I would like to share some of my ‘relearnings’ about doing peer-to-peer (P2P) appeals for insurance denials:
- Insurance denials are not personal, so don’t take them personally. Why was best answered years ago by Michael Corleone in the Godfather trilogy, “Don’t hate your enemies, it affects your judgment.”
- Many denials are made on incomplete clinical information. The peer often doesn’t know the whole story. Get the whole story and tell it vividly – this may be the first time the peer is hearing it, so make it cogent.
- Recognize that some denials are appropriate denials and learn from them. Use them for ‘Teachable Moments’: Why the INPT should have been OBS. Why the documentation was inadequate. Why the patient should have gone home from the ER. Consider insurance denials as a painful form of clinical documentation integrity (CDI).
- Do NOT just repeat the clinical record; present YOUR review of the whole clinical record.
- Read the nursing notes.
- Do NOT be limited by the current hospital record. If a patient was admitted with an elevated creatinine but no prior creatinine is referenced in the H&P – look it up. Old labs can result in overturns.
- NEVER take a Progress Note as the whole story, very often today’s Progress Note is yesterday’s note or even the day before that – pay attention for poorly or unedited copy/pasting.
- Always review the all vital signs yourself. Look for abnormal VS not mentioned in PNs. If you are not metric-minded be careful: 37.7O C looks innocuous but it is 100O F!
- Always thoroughly review the MAR. Look for PRN aerosol Rxs and PRN IV medications, etc. They may not be in PNs but can contribute to severity of illness.
- If the peer refuses to overturn the denial, ask why. An effective strategy is to inquire what would have made the case INPT. Sometimes in the discussion you find the something you need to get it overturned. Get the peer talking Medicine.
- Keep records of which doctors are having their cases denied – give them 1:1 feedback but also present the feedback at departmental meetings unblinded.
- Track denials by provider and reason, know what insurers are doing what.
- Study your peers – learn their style. Know who will consider the whole clinical picture and who will strictly adhere to MCG or IQ.
- Know the contract your hospital has negotiated with the insurer, e.g., does it allow for combining repeated admissions within 30 days. Never take the insurer’s word for it.
- Know if the MA insurer has a contract, if not it defaults to traditional Medicare guidelines.
- If the peer upholds denial just because it was only 1 MN but met their criteria (MCG or IQ) take it to their Medical Director, review the contract, and if necessary, appeal to the Centers for Medicare & Medicaid Services (CMS).
- When in doubt – always appeal.
- Always be gracious in defeat but know your appeal rights in your contract.
- Doing Multidisciplinary Rounds and doing P2Ps are synergistic.
Insurance details are opportunities, do not waste them. They are chances for PAs to learn about the state of documentation in their shop, about their staff’s comprehension of policies, e.g. Observation, and to keep up to date on clinical medicine.
Denials are also an opportunity to demonstrate the vital financial role of the PA in today’s hospitals and to this end:
20. Keep a detailed record of the denied charges you have recovered.
21. Do not keep #20 to yourself.