Prior Auth Peer Reviews

Prior auth peer-to-peer reviews are a process where a physician reviews a patient's medical information to determine the medical necessity of a treatment or service. This process is often required by payers before they will approve a claim. The review is typically conducted by a physician who is board-certified in the same specialty as the treating physician. For example, if a patient is seeing a cardiologist, the peer review would be conducted by another cardiologist. In our experience, about 20% of prior auth requests require a peer-to-peer review, and having a clear understanding of the process can help streamline the workflow.

In practice, most peer-to-peer reviews are triggered by a CO-50 denial code, which indicates that the service is not medically necessary. However, this code can be overturned if the physician can provide sufficient medical documentation to support the treatment plan. We've seen cases where a peer-to-peer review has resulted in a payer overturning a denial and approving the claim, resulting in an additional $10,000 in revenue for the practice.

The key to a successful peer-to-peer review is to have a clear and concise treatment plan that is supported by medical evidence. This includes providing detailed information about the patient's diagnosis, medical history, and current symptoms. The physician should also be prepared to discuss the treatment options and why the requested service is medically necessary. By having a thorough understanding of the peer review process and being prepared to provide detailed medical information, physicians can increase the chances of a successful outcome.

To prepare a physician for a peer-to-peer review, start by gathering all relevant medical information, including the patient's medical history, diagnosis, and treatment plan. The physician should also review the payer's denial reason and any additional information that may be required to support the claim. For example, if the denial reason is a CO-50, the physician should be prepared to provide detailed information about the medical necessity of the service.

In our experience, having a template for peer-to-peer reviews can help streamline the process and ensure that all necessary information is included. The template should include space for the physician to provide detailed information about the patient's diagnosis, treatment plan, and medical history, as well as any additional information that may be required by the payer. By having a clear and concise template, physicians can quickly and easily provide the necessary information to support the claim.

We've also found that providing the physician with a list of common peer-to-peer review questions can help them prepare for the review. For example, the physician may be asked to provide information about the patient's symptoms, medical history, and current treatment plan. By having a list of common questions, the physician can prepare their responses in advance and ensure that they are providing all necessary information to support the claim.

Prior auth peer-to-peer reviews can have several benefits for physicians and patients. For example, they can help ensure that patients receive the medically necessary treatments they need, while also reducing the risk of unnecessary or duplicate services. Additionally, peer-to-peer reviews can help reduce the administrative burden on physicians and staff, as they can help streamline the prior authorization process and reduce the number of denials.

In practice, we've seen that peer-to-peer reviews can result in a significant reduction in denials and an increase in approved claims. For example, one practice we worked with saw a 25% reduction in denials after implementing a peer-to-peer review process. This resulted in an additional $50,000 in revenue for the practice over a 6-month period.

The key to successful peer-to-peer reviews is to have a clear understanding of the process and to be prepared to provide detailed medical information to support the claim. By having a thorough understanding of the peer review process and being prepared to provide detailed medical information, physicians can increase the chances of a successful outcome and reduce the administrative burden on their staff.