Wiki Getting Paid for Peer-to-Peer Reviews

[Deb Jones - CPC]

Does anyone know of a way to get paid by insurance for Peer-to-Peer pre-authorization phone calls? The surgeons are spending a lot of time on the phone they'd rather be spending in the operating room and have asked if there's a way to bill insurance and obtain reimbursement for that time.

 

[amyjph]

I don't believe this is possible. However, if providers are getting a high amount of P2P requests it may be that the internal authorization process/workflow needs intervention. If you have a PA team are they following the requirements of the plan they are submitted PA to? Are all of the elements of the record and documentation being sent with the initial request? In my past experience, providers that had poor documentation or unclear orders, etc. experienced higher P2P calls. Are PA requests being sent without following the medical necessity criteria?

P2P can't always be avoided however, sometimes you have to look internally. Is it only one or two providers that are consistently getting hit with these?

https://www.evicore.com/insights/tip-3-how-can-i-avoid-peer-to-peer-phone-calls

https://www.priorauthtraining.org/a-look-into-peer-to-peer/

https://www.ama-assn.org/practice-management/sustainability/prior-authorization-practice-resources

https://www.aafp.org/family-physician/practice-and-career/administrative-simplification/prior-authorization/techniques-prior-auth.html

 

[sls314]

I don't believe this is possible. However, if providers are getting a high amount of P2P requests it may be that the internal authorization process/workflow needs intervention. If you have a PA team are they following the requirements of the plan they are submitted PA to? Are all of the elements of the record and documentation being sent with the initial request? In my past experience, providers that had poor documentation or unclear orders, etc. experienced higher P2P calls. Are PA requests being sent without following the medical necessity criteria?

P2P can't always be avoided however, sometimes you have to look internally. Is it only one or two providers that are consistently getting hit with these?

https://www.evicore.com/insights/tip-3-how-can-i-avoid-peer-to-peer-phone-calls

https://www.priorauthtraining.org/a-look-into-peer-to-peer/

https://www.ama-assn.org/practice-management/sustainability/prior-authorization-practice-resources

https://www.aafp.org/family-physician/practice-and-career/administrative-simplification/prior-authorization/techniques-prior-auth.html

I agree with Amy. If there are a significant number of P2P requests, I'd look to improving the internal authorization process and documentation being submitted.

Although you may not entirely eliminate P2P, you could at least reduce the volume and the amount of time your providers are spending on it. Good luck!