Unlocking The Peer-To-Peer Billing Process: Navigating Insurance Reimbursement

Peer-to-peer (P2P) insurance is a collaborative consumption concept that allows policyholders to pool their money to cover each other for various risks. This type of insurance gives policyholders more control over management decisions and allows them to receive excess premiums or donate them to charity. P2P insurance aims to save money, increase transparency, and reduce inefficiencies and conflicts between insurance carriers and policyholders. It is often facilitated by a third party, such as an insurance broker or company, and can be structured as a social network. P2P insurance reviews are also used to appeal denied claims, with the patient's physician discussing the case with the insurance company's physician.

A 'doc to doc' appeal can overturn an initial denial

A "doc-to-doc" appeal, also known as a peer-to-peer (P2P) review, is a phone conversation between a physician from an insurance company and the patient's attending physician. This conversation typically occurs when a request for services has been denied by the insurance company. During the P2P review, the patient's physician discusses the need for a procedure, medication, or treatment with the insurance company's medical director to obtain prior authorization approval or appeal a previously denied authorization.

The P2P review is a crucial strategy to avoid or overturn claim denials and prevent revenue leakage for healthcare providers. It offers a higher chance of success compared to traditional appeal processes, as it involves a peer-to-peer discussion between physicians. This conversation can go beyond the information on patient charts and documents, allowing the patient's physician to communicate and connect with the insurance company's medical director more effectively.

To prepare for a P2P review, it is essential to review the adverse determination letter, documentation submitted with the procedure request, the payer's medical coverage guidelines, the patient's medical records, and relevant evidence-based guidelines. Additionally, building rapport, staying positive, and maintaining a clinical lens during the conversation can improve the chances of a favorable outcome.

While a P2P review can be time-consuming and challenging, it is worth considering due to its potential to prevent financial losses and ensure timely access to treatment for patients. However, it is important to note that the success of a P2P review also depends on the qualifications and expertise of the reviewing physician, as well as their ability to make decisions within the required timeframe.

A peer-to-peer review is a scheduled phone call

During the peer-to-peer review, the attending physician will discuss the patient's need for a procedure, medication, or treatment with the insurance company's medical director. This conversation usually lasts only five to ten minutes and can make a significant difference in the outcome of the patient's case. It is important to be well-prepared for the call, as it can be challenging to sway the insurance company's decision. The attending physician should review relevant documentation, such as the adverse determination letter, the patient's medical records, and the payer's medical coverage guidelines.

While peer-to-peer reviews can be time-consuming and tedious, they offer a valuable opportunity to obtain approval for necessary medical care. They can also prevent revenue loss for hospitals and healthcare providers by reducing the number of denied claims. It is recommended to schedule the call when there is a block of time available and to be concise, respectful, and positive during the conversation. Building rapport with the insurance company's physician and providing objective facts can increase the chances of a successful outcome.

It is worth noting that peer-to-peer reviews are not the same as medical peer reviews, where physicians evaluate each other's work to maintain or improve standards of care.

The peer-to-peer review process is time-consuming and tedious

The process requires significant preparation and can be challenging, especially for busy clinicians who may not have sufficient time to devote to it. It involves collecting supporting documentation, reviewing the patient's medical records, and understanding the insurance company's guidelines and requirements. This preparation can take up valuable time that could otherwise be spent on patient care.

Additionally, the peer-to-peer review process can be frustrating due to the potential for unqualified reviewers. The physicians on the payer side may not have the necessary expertise in the specific medical practice area being discussed. This lack of specialization can hinder an accurate determination and lead to further delays or denials.

Moreover, the peer-to-peer review process can be repetitive and inefficient. Physicians may need to explain medical decisions and justify treatments or prescriptions multiple times, first to the insurance company's medical director and then to other reviewers. This can create a sense of redundancy and waste valuable time and resources.

To navigate the peer-to-peer review process effectively, it is essential to have a clear understanding of the requirements and guidelines. Physicians should be prepared, concise, and respectful during the conversation. Building rapport and maintaining a clinical lens can also help improve the chances of a favorable outcome.

The patient's doctor justifies the patient's medical order

The patient's doctor justifying a patient’s medical order, prescription, or inpatient status to the insurance company’s medical director is known as a peer-to-peer (P2P) interaction. These interactions occur when the insurance company denies a claim according to its internal policies and requirements. The patient's doctor must then discuss the patient's case with the insurance company's physician, who will have the final say on whether the claim is approved or denied.

The peer-to-peer review is a scheduled phone conversation that usually lasts around 5-10 minutes and is required to take place within 72, 48, or even 24 hours of the initial request. If the conversation does not take place within this timeframe, the case will be closed, and the claim will be denied.

During the peer-to-peer review, the patient's doctor will need to provide a persuasive explanation of their medical decisions and may need to supply additional clinical information or documentation to support the patient's claim. This process can be tedious and time-consuming, and there is no guarantee that the insurance company's medical director will be swayed.

While peer-to-peer interactions can be challenging and time-consuming for physicians, they offer a potential advantage over the traditional appeal process. A successful peer-to-peer review can prevent millions of dollars from being tied up in the appeal process and can result in more timely access to treatment for patients.

The insurance company's physician may not specialise in the relevant area of medical practice

When a patient's doctor and the insurance company's physician engage in a peer-to-peer (P2P) review, it is usually because the insurance company has denied a claim according to their internal policies and requirements. In such cases, the patient's doctor justifies the patient's medical order, prescription, or inpatient status to the insurance company's medical director.

While the P2P process can be an effective way to overturn a denied claim, it is important to note that the insurance company's physician may not specialise in the relevant area of medical practice. This lack of specialisation can hinder an accurate determination and, ultimately, the approval of the claim.

In such cases, it may be beneficial to request an appeal or seek alternative options for coverage. It is also worth noting that the P2P process can be time-consuming and tedious, often requiring extensive documentation and clarification. Therefore, it is essential to weigh the benefits and challenges of each case and consider alternative options if the P2P process is not successful.

Strategies for a Successful P2P Review

To increase the chances of a favourable outcome during a P2P review, here are some strategies to consider:

• Schedule flexibly: Allow for a block of time for the phone call and be prepared to wait or reschedule if needed.
• State your case concisely: Provide objective facts and clinical notes, filling in any gaps in the insurance company's information.
• Build rapport: Establish a non-combative and respectful dynamic with the insurance company's physician to lay the foundation for a mutually respectful conversation.
• Stay positive: Understand the reviewer's agenda, remain respectful, and remember that claim denials are often not personal.
• Maintain a clinical lens: Appeal to the reviewer's medical professionalism, especially when dealing with complex cases.
• Remind the reviewer of the provider/payer partnership: Advocate for your patient, who is also the insurance company's member, and politely request a well-structured call with a complete review.

Frequently asked questions