Peer to peer

Specialties Case Management

Published

Hi everyone!

I'm a new hospital CM. I recently had a case where the insurance company denied the INPT status and approved Obs. They provided the peer to peer info. So I called the MD and informed him. Needles to say, he wasn't pleased that I was asking for a peer to peer. How do you handle these types of situations? Do you normally inform the MD that the insurance denied and that a peer to peer is offered?

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"Needles to say". LOL. but to answer your question: Yes.

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Hi d'cm,

Thanks for the reply! Any advice on how to give this info without being yelled at? Lol!

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It might not make any difference to the doc in the least. They get paid the same.

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Yea, you're right lol!

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"I'm sure you don't want to hear this and I'm sorry to have to tell you, but ... "

(if / when grumbling ensues...)

"Don't shoot the messenger."

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Specializes in Med/Surg, Step-Down, Case Management.

Yes, I agree with GrnTea. I would simply tell the doc, "The payor has downgraded the status to OBS. If you disagree with the decision, you can do a peer to peer." If he snaps back at you, tell him you are only trying to advocate for the patient.

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Thank you everyone for the great advice! I'll be using all of your suggestions ?.

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You are viewing the process incorrectly.

If an admission is denied, your role is to inform the physician... period. Doc knows the drill.

It is NOT your call to request a peer to peer.. only the physician can do that. In essence you were telling the doc YOU wanted a peer to peer.

It all comes out in the wash, anyway.. when the denial is appealed.

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It might not make any difference to the doc in the least. They get paid the same.

In the long run, yes. However many docs take it as an affront to their judgement and get their panties in a bunch. If their panties are bunched.. the DOCTOR requests a peer to peer at that time.

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"I'm sure you don't want to hear this and I'm sorry to have to tell you, but ... "

(if / when grumbling ensues...)

"Don't shoot the messenger."

Dang GrnTea... we NEVER say we're "sorry" to a doc.. ever.

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Be sure to include this type of discussion with your Physician Advisor - they are your best resource when having communication issues with a specific MD.

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