Peer to Peer - Pearls and Pitfalls

Scott M. Brenner, MD, FAAP 

Peer to peer discussions represent a significant aspect of Physician Advisor work. These have evolved as payers continually change both their approach to payment and their use of evidence-based criteria. In the past, these discussions were primarily a forum for two physicians to dissect a case and determine if, in fact, the patient was most appropriately cared for in the inpatient setting. As time has elapsed, the decisions of Medical Directors have become largely criteria based, especially during the initial 48 to 72 hours of the patient’s hospitalization. Physician Advisor success can be improved when certain strategies are employed. 

First and foremost, if the discussion centers around criteria, it is important to understand the criteria that they are using and to point out cases where the patient in fact does meet criteria for inpatient admission, specifically based on those criteria utilized by the payer. While most payers will tell you that criteria are only a guideline, a majority of medical directors will use these to deny cases. However, if the patient does in fact meet criteria, pointing this out will often quickly end the discussion in favor of the Physician Advisor. For example, Milliman require a bump in creatinine to three times baseline. It is therefore critical to know the baseline of the patient and if their creatinine during the hospitalization meets this criteria point. If so, the Physician Advisor will prevail. 

Although criteria have become a mainstay of these discussions, many Medical Directors will approve the case if the patient has been in the hospital “beyond a reasonable observation timeframe and continues to be symptomatic or receive appropriate inpatient care. Therefore, articulating the condition of the patient on hospital day three and being specific about abnormal vital signs, persistence of symptoms, abnormal labs and specific interventions will often result in a favorable outcome for the hospital. In addition, discussing the complexities of an individual patient with regard to a specific diagnosis and/or treatment plan can go a long way in ensuring that the case is viewed favorably by the Medical Director. 

Patients with multiple comorbid conditions can present greater difficulties in management. For example, a patient with an acute exacerbation of CHF who has concomitant chronic kidney disease results in greater complexity of diuretic management and fluid balance. In other cases, although any specific problem may not meet criteria, discussing the multiple medical issues being managed and the interplay of these issues in developing a management strategy can again often result in a favorable outcome of the peer to peer discussion. 

Medical directors often don’t have all of the information. Providing additional information and articulating the need for ongoing care in the inpatient setting is often enough to prevail in peer to peer conversations. In addition, it is useful to remember that Medical Directors are colleagues and not adversaries. Their job is to represent the insurance company and the job of the Physician Advisor is to represent the interests of the hospital. In both cases, each physician believes that they also represent the interests of the patient. Being cordial, but direct, in these conversations will assist in more favorable outcomes for the Physician Advisor. Of course, the role of the Physician Advisor goes beyond interactions with the payer. Assisting hospitals in ensuring that patients are in the correct status and that progression of care is appropriate will reduce the number of denials and as a result, the number of peer to peer discussions needed. 

Always being prepared with the necessary information to conduct a peer to peer, an understanding of the criteria being used and a broader knowledge of the patient’s overall condition and it’s effect on the care being provided will certainly result in an increase number of favorable outcomes for the Physician Advisor.