Four signs peer-to-peer reviews might be a problem in your hospital

Feb 11, 2021 For Providers

If you’re struggling to maintain healthy margins in your hospital return, it can be difficult to identify the culprit. It could be anything from too many denials to appeals that just don’t get done, or a host of Utilization Management issues in between.

Do you need help identifying the issues with your hospital return?

We’re investigating five questions that can help you determine if your hospital is leaving revenue on the table. Check out our previous question for more insights: Are you getting too many denials from health plans? Next week we'll explore the impact of documentation on care reimbursement.

Why peer-to-peer reviews matter

Peer-to-peer reviews are often overlooked as a way to maintain a more healthy bottom line. Just one phone call can result in valuable reimbursement for your hospital. Do you have difficulty getting your physicians to do these reviews with health plans? 

Peer-to-peer reviews matter. When done correctly, they can result in increased financial returns for your facility. But these calls are difficult to do well, and it’s often challenging to get physicians to place the calls in the first place.

Peer-to-peer reviews can be a burden to doctors

Your physicians are busy caring for patients and completing the required documentation for their care. The physician’s concern is getting their patients appropriate care, not ensuring that the hospital gets paid for that care. 

Peer-to-peer reviews are an additional burden for physicians who are already stretched too thin. Time spent conducting peer-to-peer reviews is time not spent caring for patients. There’s no real internal motivator for your physicians to take the time to conduct a peer-to-peer review.

Many physicians lack the confidence that peer-to-peer reviews are worth doing. Their experience may be that the reviews have little impact, and they seldom see a health plan reverse a denial because of their efforts. Additionally, the outcome of the peer-to-peer review has no impact on their patient care. 

Peer-to-peer reviews are difficult to do well

Even if you can get your physicians to make the call, peer-to-peer reviews are difficult to do well. Many physicians only make a few of these calls a year, and few fully understand the process or the requirements for these calls. It isn’t enough to be a good physician; your physicians need to have adequate skills and training to conduct effective peer-to-peer reviews.

To conduct a good peer-to-peer review, a physician needs to understand what the health plan representative is looking for to be able to approve care. The health plan is concerned with the criteria of care, so the physician needs to have some understanding of that criteria before conducting their peer-to-peer review. By speaking directly to the criteria, a physician can preempt concerns where perhaps the criteria weren’t met but other symptoms indicated a need for care.

Physicians become better at peer-to-peer reviews with experience, but that experience is difficult to gain when they only conduct a few reviews each year. If you want to see more effective peer-to-peer reviews in your hospital, you need to have physicians who are compensated for their calls and dedicated to these reviews rather than trying to fit them in between pages in the ER or when they’d rather go home. 

Peer-to-peer reviews can be intimidating and difficult to conduct well, yet they’re an essential part of any strategy for maintaining a healthy hospital return. The following questions can help you identify whether peer-to-peer reviews are a problem in your hospital.

Indicators that peer-to-peer reviews might be a problem

  1. Do your physicians know how to do peer-to-peer reviews with health plans?
    In order to overturn denials with a peer-to-peer review, your physicians need to understand the process well. 
  2. Do you have qualified people doing your peer-to-peer reviews?
    Not all physicians make good peer-to-peer reviewers. To see cases overturned, your reviewers need to be experienced in the process.
  3. Do you have a history of uncompleted peer-to-peer reviews?
    Statistically, 30% of peer-to-peer reviews are never even completed. Physicians have few internal motivations for completing peer-to-peer reviews.
  4. Are your reviews resulting in overturned denials?
    To have an effective peer-to-peer review, the reviewer not only needs to know the case but also needs to understand what the health plan requires in order to overturn the denial. This takes time and preparation.

Cadenza can help

Our team of board-certified physicians has extensive experience with peer-to-peer reviews. We can make peer-to-peer reviews on your behalf and, through this process, audit charts, documentation, and communication within your facility. We create a targeted intervention for peer-to-peer reviews and can train your core team members in conducting effective reviews with health plans.

To see how we can improve your return through effective peer-to-peer reviews, request a free consultation with our team

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