When a payer wants to understand why a client needs a certain level of care, they review how well the clinical picture translates on paper. Because notes can only convey so much information, a peer-to-peer review can be very helpful. Not only does this meeting allow your clinician to discuss the case with the decision maker face-to-face, but for behavioral health providers it can mean the difference between same-day authorization and a lengthy appeal process.
Let’s dive into what a peer-to-peer review is, when it’s appropriate to request one, and how to set yourself up for success.
What Is a Peer-to-Peer Review?
Peer-to-peer reviews are exactly what they sound like: a meeting between you and a physician or clinical reviewer who works for the insurance company. This can be done over the phone or video and will typically occur after the payer has already made an adverse determination on your prior authorization or concurrent review request.
The purpose of a peer-to-peer is simple: provide the reviewer with information that may not have been evident in the written documentation. This can include symptom presentation, risk factors, and history in the client’s own words that demonstrate the requested level of care is medically necessary.
Peer-to-peer reviews can be very effective and can help you avoid filing a formal appeal.
When Your Clinician Should Ask for One
The most common reason a peer-to-peer review is scheduled is a medical-necessity denial for a prior authorization or a continued stay. This could look like a payer declining an authorization for residential treatment, cutting an IOP stay short, or deciding a client should step down to a lower level of care sooner than your team believes.
Timing is extremely important in peer-to-peer reviews. Many payers only allow these requests within a short window after determination, sometimes just a few days. Others offer it before a final decision is issued, when a reviewer is leaning toward denial. Make sure that your billing or utilization review team knows each payer’s rules so that they’re able to act quickly if a denial comes in.
It’s also important to understand that a peer-to-peer review generally doesn’t replace the formal appeals process. If the call doesn’t go your way, your appeal deadlines are usually still running, so keep tracking them.
How to Prepare for the Call
The clinician on the call should be someone who knows the client well, such as the treating provider. When they have the call, they should have the following information on hand:
- Denial reason and the criteria the payer used
- Client’s current symptoms
- Safety concerns
- Co-occurring mental health or medical conditions
- Unsuccessful attempts at lower levels of care
- Client’s home environment
- Risks of relapse
Keep in mind that reviewers typically have limited time. A focused, organized explanation tends to work better than a long, general defense of the treatment plan.
What to Do After the Call
The most important thing to do after the call is document everything:
- Date and time
- Reviewer’s name and credentials
- Reference number
- Information discussed
- Authorization details (if the denial is overturned)
If the denial is upheld, ask the reviewer to clarify what information would have changed the outcome. Not only can this information strengthen your written appeal, but also it can help your team document more effectively for future cases.
Make Every Peer-to-Peer Review Count
The most successful peer-to-peer reviews happen when clinical and behavioral health billing teams are on the same page. Clinicians bring their case knowledge, while billing and utilization review staff keep track of deadlines, payer rules, and the overall paper trail that supports any appeal.
Integrity Billing helps behavioral health providers stay on top of denials, peer-to-peer requests, and appeals so fewer claims fall through the cracks. Wondering how many of your denials could have been resolved earlier? Request a free forensic assessment from Integrity Billing. We’ll review your denials, spot missed opportunities, and show you where your process can improve, at no cost and with no obligation. Contact Integrity Billing today at 888-368-7461 to get started.