Tip #3: How can I Avoid Peer-to-Peer Phone Calls?

In our first two blog posts on how to avoid peer-to-peer (P2P) phone conversations, we shared some tips on how to make the process of obtaining prior authorization easier and more efficient for clinicians and administrators. The best way to avoid denials, appeals, and P2P phone conversations is to obtain prior authorization “right out of the gate” when your office’s prior authorization employee (PAE) makes the initial request for an approval number. During the initial request before the case is submitted, is the best time to thoroughly gain an understanding of the evidence-based guidelines eviCore uses to determine medical necessity, reference the quick reference tools available, and verify that all documentation validating compliance is complete. Our goal in these blogs is to provide you with the tips, tools, and other necessary information to make the process easier for everyone.

One important tip is that utilizing the eviCore web portal is the fastest, easiest, most efficient way to obtain prior-authorization. While it is important to have all the relevant information prepared prior to initiating a request, utilizing the website takes approximately 3-5 minutes, as opposed to speaking with a representative on the phone.

Here is how our prior authorization process works, using an example of an imaging study.

When the PAE contacts eviCore to request a case or initiates a case through the web portal, our phone representative conducts a quick identification. We identify the patient, the insurance company, the imaging facility, the imaging study, and the reason for the request. With this completed, the case has the potential to be auto-approved after minimal information is provided. If the case is not auto-approved, the PAE is transferred to a nurse reviewer who then asks a series of relevant clinical questions.

eviCore uses an automated decision support system that analyzes the PAE responses to the clinical questions. At times, the system will approve the request based on only a few of the responses. Other times, the nurse reviewer will enter all of the clinical responses into the patient’s data base. While the nurse is typing the answers, he/she is also comparing the responses to eviCore’s evidence-based guidelines seen on another computer screen.

There is nothing magical or secretive about the clinical questions. They are the “who, what, when, where, and how” questions that most providers were taught in school: “What is the problem (e.g., pain, swelling); when did it begin; where is the problem located; how did it occur (e.g., injury, fall, trauma)? The nurse reviewer may also ask if any other imaging studies (x-ray, ultrasound, ECG) have been completed; when the patient sought treatment; what kind of treatment was given; and how long the treatment lasted. For many suspected diseases, the typical questions are available on the eviCore website.

It’s important to understand that eviCore intake nurse reviewers are able to approve any imaging study requested, but they are not authorized to deny any study. If the clinical responses meet the guidelines, the nurse can approve the request immediately and issue a Prior Authorization (PA) number. If the responses do not meet the guidelines, the nurse specialist must pass the case on to one of our medical directors for review. For example, if the guidelines call for a plain x-ray before a CT chest and the PAE does not have the result of the x-ray, the nurse specialist cannot approve the request and will then send the case to a medical director.

Once a medical director reviews the case, his or her options include:

1. Approving the request.

2. Denying the request and providing a reason for the denial.

3. Denying the request and providing an alternative recommendation (alt-rec) – a reason must be given as well.

The difference between a denial and an alt-rec is simple. The alt-rec denies the requested study but offers an alternative imaging study that eviCore will approve. For example, the alt-rec may indicate, “We cannot approve the CT chest without and with contrast, but we will approve a CT chest with contrast only.”

If there is a denial with an alt-rec, eviCore will call your office and offer the alternative imaging study. If it is accepted, the denial is overturned, a PA number is issued for the alternative study, and that number is given to your office staff.

If there is a denial where an alt-rec is declined by the provider’s office, an array of appeals and reconsiderations are allowed, all of which require submission of additional clinical information. The most time-consuming of the appeals involves conducting a P2P phone call, in which a provider must speak on the telephone with a medical director. Again, the P2P may result in upholding the denial; issuance of a different alternative recommendation; or the denial may be overturned and approved, based on the exchange of clinical information between the provider and medical director.

Take Home Point #3: The fastest and most reliable way to avoid P2P phone calls and other appeals and obtain the prior authorization number “right out of the gate” on the very first submission is to be prepared to answer the clinical questions that will be asked.

 

Author: Robert L. Neaderthal, M.D.

Robert L. Neaderthal, M.D. has been a medical director at eviCore healthcare for seven years. Prior to joining eviCore, he served for 30 years as a primary-care internist in Nashville, Tennessee. Since joining eviCore, Dr. Neaderthal has been committed to helping other providers avoid peer-to-peers by educating them on ways to avoid denials.

For more tips on how to avoid peer-to-peer phone calls, read our other tips as part of the “How Can I Avoid Peer-to-Peer Phone Calls” series here. For questions regarding this topic, please email onlineinfo@evicore.com.

Clinical Guidelines: a Brief History

Clinical guidelines advise healthcare professionals about the most appropriate treatment or care for people with a particular condition such as lower back pain or cancer. Informally, clinical practice guidelines have been a fundamental component of medicine since healers first discussed how best to manage patients.

The first known formal clinical guidelines may have been written by Hippocrates. Credited with advancing the systematic study of clinical medicine, he summed up medical knowledge and prescribing practices for physicians in the Hippocratic Corpus, works written for both specialists and lay people, sometimes from opposing viewpoints. This library of medical text written between the sixth and fourth centuries BCE probably contained the earliest clinical guidelines.

The modern age of guidelines began with a 1992 Institute of Medicine (IOM) report, which defines guidelines as “systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances.” Now there are numerous guidelines produced by medical societies (such as the American College of Cardiology) or governmental bodies (such as the Agency for Healthcare Research and Quality).

Who Participates in Clinical Guideline Groups?

The individuals appointed to devise—or update—clinical guidelines include healthcare professionals, researchers, patients and caregivers. All have specific knowledge of the clinical domain. In addition, this collaborative approach to guideline development ensures that best practices from a variety of settings and viewpoints are incorporated to produce the best outcomes for patients.

The initial development of guidelines typically includes the following steps:

  • Identify and delineate the subject area (e.g., cancer, back pain)
  • Convene and lead a guideline development group made up of subject-matter experts
  • Assess evidence about the clinical question or condition
  • Translate evidence into a recommendation
  • According to the Institute of Medicine Standards for Developing Trustworthy Clinical Practice Guidelines, for each recommendation, the following should be provided:
    • An explanation of the reasoning
    • A rating of the level of confidence in the evidence underpinning the recommendation
    • A rating of the strength of the recommendation by utilizing a scale such as the one developed by the American Academy of Family Physicians
    • A description and analysis around any differing opinions regarding the recommendation
  • Review the guideline by utilizing systematic reviews approved by the Institute of Medicine Committee’s Systematic Reviews of Comparative Effectiveness Research.

Guideline development groups (GDG) must have the time, resources, and skills to scrutinize evidence and make objective value judgments based on their expertise, clinical studies on the subject matter, and analysis of the medical evidence available to them. Group members must be free of conflicts of interest, and are required to declare all interests and activities resulting in any potential conflicts of interest by written disclosure to those convening the GDG. Some ideal characteristics of groups that author these clinical guidelines are that they are multidisciplinary, and gender and geographically-balanced.

The group will appoint a writer as well as a chair, who should be an expert facilitator. Many groups include a methodologist, an expert in guideline development process to ensure that the standardized articulation of recommendation is met, and an economist, who can advise on economic benefits and drawbacks of recommendations.

What Do Guidelines Include?

Guidelines include various clinical support content, such as the risk factors for conditions; diagnostic criteria; prognostics with and without treatment; the benefit and harm of various treatment options; resources associated with different diagnostic or treatment options; and patients’ experiences of the options.

The 1992 IOM report suggested that every set of clinical guidelines also include information on the cost implications of alternative, preventative, diagnostic, and management strategies for each clinical situation.

Guidelines are required to use clear language. Vague or nonspecific wording should be avoided, as clinicians may have difficulty knowing the precise contextual meaning of phrases such as “clinically appropriate” or “if necessary.” The manner in which guidelines are developed and funded must also be transparent and publicly available. As each new guideline is developed, it is important to ensure that all relevant external stakeholders have reviewed the guidelines prior to publishing.

Additionally, guidelines, created to improve patient care, must be updated as new research emerges so they do not lose their clinical relevance.

Tracing the Path and Significance of Prior Authorization

Health insurers require prior authorization (PA) for certain healthcare services, treatment plans, prescription drugs, and/or durable medical equipment before a patient can receive them. The determination focuses on whether the service, drug, or product is medically necessary. It does not guarantee that the insurer will cover the cost.

The PA process—and research into its effectiveness—dates back more than 25 years, when states began analyzing how to curtail drug costs within the Medicaid program. The Omnibus Budget Reconciliation Act of 1990 included PA among explicit provisions for limiting drug coverage and cutting costs. The legislation also required the Health and Human Services Secretary to study the impact of PA programs on beneficiary and provider access to prescription drugs as well as on program costs, and to make recommendations for PA reforms if needed.

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When Does Medical Testing Become Unnecessary or Even Harmful?

Recently, well-known bioethicist Arthur Kaplan and his fellow researcher, radiologist Dr. Stella Kang, raised an important question: Does the growing tendency to offer more and more medical tests inadvertently harm some patients?

“How can radiologists fulfill the ethical obligation to support patient interests when very low-risk incidental findings concern patients for different reasons and lead to excessive resource utilization?” wrote Kang, Kaplan and other researchers from NYU Langone Medical Center in the Journal of the American College of Radiology.

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Prior Auth Needs Improvement (there, we said it)

As a doctor, your work day is full of challenges. The truth is, we understand that the old way of managing prior authorization can be cumbersome and inefficient. So that’s why we are changing things. Watch our video below to find out more about how eviCore is working to streamline the entire utilization management process and make it easier for you to give your patients the best care possible.