Peer-to-Peer Reviews for Medical Necessity Appeals: Key Strategies for Revenue Recovery

The peer-to-peer stage of the authorization process is the single most effective point for overturning medical necessity denials. This critical juncture prevents revenue loss. Here’s a closer look at why this step matters and how hospitals can improve their approach. 

Why Peer-to-Peer Reviews Matter 

Medical necessity denials are a common challenge for hospitals, often resulting in lost revenue and increased administrative burdens. The peer-to-peer review process provides an opportunity to challenge these denials by engaging directly with payor medical directors. When executed effectively, a robust peer-to-peer process mitigates payor denials and protects earned revenue.  

Understanding the Peer-to-Peer Process 

Overcoming Common Challenges 

Hospital-based physicians often face difficulties when tasked with engaging in peer-to-peer discussions. These challenges include: 

• Time Constraints: Balancing patient care responsibilities with the demands of appeal processes can strain resources. 

• Limited Experience with Payors: Physicians often lack familiarity with payor medical directors’ tactics and arguments. 

• Emotional Stress: Advocating for medical necessity in a high-pressure conversation can be daunting for those unaccustomed to the process. 

Hospitals can address these obstacles by equipping their teams with the necessary training, resources, and support to confidently navigate the peer-to-peer process  

Key Metrics to Evaluate Success 

Three metrics are critical in assessing the effectiveness of peer-to-peer strategies: 

• Pursuit Rate: This refers to the frequency with which hospitals pursue peer-to-peer calls for denied inpatient status. High pursuit rates demonstrate a proactive approach to denial management. 

• Overturn Rate: This represents the percentage of denials successfully overturned when a peer-to-peer is performed.  A strong overturn rate reflects the effectiveness of the argumentation and advocacy employed. 

• Effective Overturn Rate: This represents the overturn rate for peer-to-peers when all opportunities are considered.  

Optimizing Net Revenue Impact: The Pursuit-Overturn Matrix 

Pursuit rate and overturn rate metrics should be evaluated to ensure that hospitals optimize for maximum net revenue impact rather than just a high overturn rate. A higher pursuit rate, even with a slightly lower overturn rate, can lead to greater overturned cases, which has a stronger positive financial impact. 

For example:

In the first scenario, the overturn rate appears stronger (80% vs. 60%), but the second scenario results in six more overturned cases, which—assuming a payment difference of $5,000 per case—translates to $30,000 more in recovered revenue. This demonstrates why optimizing for the highest positive net revenue impact, rather than just a high overturn rate, is critical. 

Enhancing Your Peer-to-Peer Strategy 

An effective peer-to-peer approach involves engaging in the process to master it. Hospitals can improve their strategies by: 

1. Building Expertise: Training staff on payor guidelines and common denial tactics. Partnering with organizations like Brundage Group can provide access to seasoned Physician Advisors with deep experience in payor interactions and appeals. 
2. Focusing on Collaboration: Encouraging a team-based approach to appeal processes and leveraging external support to alleviate administrative burdens. 
3. Leveraging Technology: Using data analytics to track trends, identify denial patterns, and optimize processes. Brundage Group’s comprehensive data tracking keeps hospitals informed about outcomes and helps identify areas for sustainable improvement. 

By incorporating these strategies and collaborating with experts such as the Physician Advisors at Brundage Group, hospitals can build a more robust, proactive denial management program that improves success rates and enables the hospital-based physicians to focus on patient care. 

How Brundage Group Can Help

Brundage Group specializes in managing the peer-to-peer process from start to finish. Our seasoned Physician Advisors bring extensive experience and collegial relationships with payor medical directors, supporting a strong advocacy approach. 

We offer: 

• Comprehensive scheduling and facilitation. 

• Data tracking to hold payors accountable and to identify denial trends. 

• Expertly drafted written appeals for cases that require additional support. 

With a 93%+ pursuit rate and a 65%+ overturn rate, our proven compliant methods help hospitals recover denied revenue while reducing administrative burdens. 

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