When to use peer-to-peer reviews in your hospital

Apr 15, 2021 For Providers

Peer-to-peer reviews can be an important part of your strategy to maintain a healthy bottom line in your hospital. One phone call can result in health plan approval, eliminating the need for a formal appeal. But it’s key to know when to conduct a peer-to-peer review; overuse of these reviews can result in adversarial relationships with health plans. Our doctors believe that there are four times you should always conduct a peer-to-peer review with your health plans.

Peer-to-peer reviews for cases that meet criteria

It’s always a good idea to conduct a peer-to-peer review on cases that you believe meet the criteria the health plan is applying, but have still been denied. There may be missing or incomplete physician documentation, and a peer-to-peer review can fill in those gaps without the need for an appeal

It’s also important to make sure you understand the criteria the health plan is applying. When conducting a peer-to-peer review in these cases, your physicians should always directly address the applied criteria.

Peer-to-peer reviews for transitional care denials

Transitional care denials are common, and it’s worth it to do peer-to-peer reviews on these cases. These reviews provide physicians with an opportunity to explain the rationale for a patient’s placement, even if it doesn’t specifically meet the health plan criteria. In these transitions of care, there may be circumstances that can’t be relayed through the documentation or the medical records.

For example, many patients go straight home after a total knee replacement. However, a patient may have acute issues that necessitate placement in a skilled nursing facility or even inpatient rehab. The patient may be able to walk the required distance down the hall for safe discharge to home, but the documentation may not clearly address that the walking is labored or that she is a fall risk. If the patient is also presenting with a UTI and has had difficulty keeping her blood pressure up, her post-surgical transition of care may be less straightforward. 

The peer-to-peer reviews on these more complex cases can be really helpful to health plan medical directors. Remember, medical directors can only make decisions based on the information that they have; a phone call from a physician provides valuable information and additional insight. 

However, only conduct peer-to-peer reviews on transitional care denials when you truly believe the patient needs this care. This requested care should be medically necessary, and the peer-to-peer reviewer should be prepared to explain the appropriate rationale for the requested care.

Peer-to-peer reviews for non-diagnostic inpatient cases

Sometimes it can be difficult for a health plan to see how sick a patient is based on the documentation. One reason for this is incomplete physician documentation. But another reason for this may be that the patient has a non-diagnostic work-up. When the labs are inconclusive, the documentation may not clearly demonstrate the true condition of the patient.

While the health plan needs to make a determination on classifying the patient as inpatient or observation, the patient’s diagnosis may not be clear within the first two days. For example, a patient who is experiencing confusion, a possible UTI, and a suspected stroke may not have a clear diagnosis after two days. But the patient is noticeably different from their baseline, and it would be unsafe for the patient to go home, even though the documentation is inconclusive. A peer-to-peer review for this case may quickly reveal this patient’s need for inpatient care, despite the documentation.

Peer-to-peer reviews: the two-midnight rule

Medicare Advantage plans apply the two-midnight rule differently for inpatient and observation, but most health plans will carefully consider whether patients that stayed less than 48 hours truly need to be categorized as inpatient. 

Shorter stays usually indicate milder problems, but this isn’t always the case. Patients who code and die within 48 hours should also receive inpatient classification for the high-level care they required. In other cases, some truly sick patients will be released from the hospital within 48 hours.

Many patients with diabetic ketoacidosis require a three-to-five day hospitalization. But in some cases, aggressive treatment can allow these patients to return home in less than 48 hours. This is a serious illness, and the care warrants an inpatient admission regardless of the length of stay for these patients.

Conduct a peer-to-peer review whenever you have a seriously ill patient who was admitted for less than 48 hours but was classified as observation. However, make sure to only use these peer-to-peer reviews for patients who were seriously ill; the case should meet criteria, regardless of length of stay.

Choose your peer-to-peer reviews wisely

While peer-to-peer reviews can be helpful in certain cases, be sure to utilize them wisely. Your hospital should avoid conducting peer-to-peer reviews on all denied cases. This is an abuse of these reviews and can create a negative bias towards your hospital with health plans. 

You should also remember that courtesy and concern matter in peer-to-peer reviews. At its essence, a peer-to-peer review is a doctor advocating for the care a patient needs. No matter what the health plan determines, remember that a peer-to-peer review is a call between professionals.

Dr. Scott Caldwell, Senior Medical Director at Cadenza Health, says of peer-to-peer reviews, “If you’re in doubt about the health plan’s decision for a patient’s care, make the call. The health plan is there for that. But beware of crying wolf.” You want to ensure that you make timely, appropriate, and courteous peer-to-peer review calls on behalf of your patients.

If you’re struggling with peer-to-peer reviews, Cadenza can help. Our team of board-certified physicians has extensive experience with peer-to-peer reviews, and we can make these calls on behalf of your hospital. Additionally, we can create a targeted intervention and strategy for peer-to-peer reviews so that you can maximize the benefit of these reviews in your hospital. And because many physicians don’t have much experience with peer-to-peer reviews, we can train your core team members in conducting effective reviews. 

To learn more about how Cadenza can help you improve peer-to-peer reviews in your hospital, request a free consultation with our team.

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