When a commercial payor makes an adverse determination, you can more effectively make your case by following these steps.
Let’s face it. Managed care is here to stay.
Interactions with your patients’ insurance companies are becoming a common occurrence when you order a polysomnogram or an in-lab PAP titration. One of the most frequent communications with a commercial payor may be the peer-to-peer review. While speaking with the insurance company can be a nuisance, if you follow a few easy steps the peer-to-peer review process can be simple and beneficial to you and your patient.
The peer-to-peer review is your opportunity to discuss an adverse determination with another peer designee from a commercial payor. The most effective peer-to-peer reviews are those discussions where the ordering healthcare professional has new clinical information to present to the insurance company that could reverse an adverse determination.
This review is typically done as a scheduled phone call between a payor’s physician representative and the qualified healthcare professional who has requested the review. Although the reviewer is a delegate of the insurance company, the peer physician receives no financial incentive to deny or to approve a request. The reviewer must be able to apply the health plan’s medical coverage guidelines to the clinical information, use clinical judgment, and render an appropriate decision.
A physician, nurse practitioner, or physician’s assistant may request a peer-to-peer review. Keep in mind that the peer you speak with may be a physician trained in a specialty outside of sleep medicine. For example, you may be discussing narcolepsy with a rheumatologist!
Carefully review the adverse determination letter. It will explain why the requested service was denied and will also explain the appeals process.
Confirm that the correct documentation was sent with the procedure request. A sleep study request is often denied for lack of information. Did you submit a diagnostic sleep study with your PAP titration request? Did you send the most recent chart notes? Did you submit supporting information about your patient’s comorbid conditions? You will need to explain why an in-lab sleep study is the only option for your patient.
Be certain that the test you requested is actually the one being denied. A common error is a request for PAP titration being erroneously processed as a split night test because both requests have the same CPT code (CPT 95811).
Consider redirection to an alternate test or treatment. Is the insurance company redirecting your patient to a home sleep apnea test or auto-PAP? You may choose to accept the alternate procedure recommendation instead of pursuing a peer-to-peer appeal. You will likely need to submit a requisition for the new test.
Review the payor’s medical coverage guidelines for the requested service. The insurance company posts its coverage policies on its website. Use the search feature on the company’s website to locate the specific document.
Schedule the peer-to-peer review at a time when you will be readily available. You will be given a time window of 1 hour or more in which the phone call will take place. Be sure to provide a phone number where you can easily be reached. This may be an office phone number or a cell phone. Also, it is helpful to specify your time zone to avoid any scheduling mishaps.
Re-examine your patient’s chart in preparation for the phone call. Do you have your talking points prepared for the call? Consider any additional information such as lab results or PAP compliance reports that may support your case. Have the medical coverage guidelines readily available, if needed.
Notify your staff that you are expecting a peer-to-peer phone call from the insurance payor. If you are in the office seeing patients, ask your staff to alert you when the call is received. You may have to interrupt your schedule to take the phone call. Typical call duration is about 5 to 10 minutes. The peer-to-peer physician will make several attempts to contact you. If you are unavailable or if a conflict arises, be sure to reschedule your appointment as soon as possible.
- Explain your case. Be succinct and provide facts from the clinical notes. Peer reviewers often hear comments like “I don’t believe in home sleep apnea testing,” but these are not useful in stating your case.
- Support your case. You may be asked to send additional documentation to the insurance company to assist in the decision. Do so in a timely manner so the decision can be rendered.
- Consider alternatives. The physician reviewer may offer an alternate approach. For example, “Let’s try the home sleep apnea test first. If that is not diagnostic, then a polysomnogram could be considered.”
- Document the outcome. Typically, the decision is made at the conclusion of the call. Be certain to get an authorization number, if provided. Verify the peer physician’s name and credentials.
- Understand the next steps. If the decision to deny the request is upheld after the peer-to-peer phone call, you or your patient can request a next-level appeal. This may involve a written appeal or an appeal with an external reviewer coordinated by the payor. Appeal rights are detailed in the letter you and your patient receive from the commercial payor.
The peer-to-peer review process is your opportunity to offer additional information to the commercial payor for consideration when an adverse determination has been made. Knowing the medical coverage guidelines for the payor and being prepared for the peer-to-peer call will increase your likelihood of a successful outcome!
Amy J. Aronsky, DO, FAASM, is medical director at CareCentrix Inc and a member of Sleep Review’s editorial advisory board. She has conducted hundreds of peer-to-peer interactions.