Resources for Clinicians:
Peer-to-peer reviews: preparation and best practices
Peer-to-peer reviews – preparation and best practices
Clinicians treating patients with mental health and/or substance use disorders may encounter required discussions with health insurer “peers” in connection with (a) prior authorizations, (b) progress check-ins, (c) medical necessity determinations, and (d) similar “reviews,” quality oversight, or appeals.
The resources below support preparation and patient advocacy during peer-to-reviews:
Five suggestions for peer-to-peer reviews (a short video)
(in development)
Potential “agenda” for the call, plus specific talking points
The reasonable goals for a peer-to-peer review for a treating clinician are:
- Alignment with the peer reviewer regarding the treatment plan, including level of care;
- Clarity/specificity regarding the peer reviewer’s competence, preparedness, and basis of assessment for coverage; and
- Go-forward plan for documentation of coverage or path to resolution of coverage
With these goals in mind, below is an “agenda” and potential talking points for a peer-to-peer discussion. The downloadable worksheet accompanying this guidance support your note-taking for future reference.
- Summarize case, including patient age, gender, demographics, and new clinical information
- Required treatment and level of care for [patient] – this primary goal of the treating clinician for the peer-to-peer discussion is articulated at the start.
- Peer clinician background and competence – what clinical training and practice does the peer reviewer have in support of this review?
- Basis of peer assessment – providing updated patient information and clinical standard of care as applied to this review
- Coverage status, clarifications, path to a determination – is the patient’s condition and the treating clinician’s plan understood?; what possible next steps to secure coverage?
- In case of an adverse determination (e.g., no coverage or delayed resolution), potential paths forward.
- Documentation requests – to request and confirm documentation from the clinical reviewer
Preparation for clinical discussion
The primary goal of the treating clinician for the peer-to-peer discussion is discussion of the patient’s current status, related risk management, and treatment plan for purposes of evaluating quality of care and determining insurance coverage.
Potential reasons for coverage decisions denying or modifying the treating clinician’s plan may include:
- Determining medical necessity based on an insurer’s proprietary standards, not generally accepted standards
- Coverage of care limited to stabilization, instead of care supporting treatment and recovery
- Treatment plan is deemed experimental by the insurance company
Preparation should specifically anticipate these potential differences.
Ideally, the clinical reviewer would use the same criteria as applied by the treating clinician. As such, asking about the criteria used by the reviewer may be helpful (e.g., ASAM, LOCUS) to effectively challenge their determination.
And, if the criteria used by the peer reviewer are not within generally accepted standards, it may be helpful for the treating clinician to refer to the applicable generally accepted standards and their appropriateness for the patient’s specific treatment and recovery.
Documentation of the peer-to-peer discussion
The downloadable worksheet supports your inquiries and documentation of the discussion, including:
- Patient and clinician info
- Peer background and clinical competence
- Basis of peer reviewer assessment
- Documentation requests
Cover My Mental Health always recommends documentation of conversations with insurance company representatives about coverage, such as:
- Prior authorizations,
- Medical necessity determinations,
- Appeals, including formal appeals filed by the patient, subsequent external reviews; and
- Formal insurer complaints, regulatory complaints, and litigation.
Contemporaneous documentation of the clinical discussion, as well as provision of a timely medical necessity letter may also be essential to securing the patient’s insurance coverage.
After the call: potential follow-ups and next steps
If coverage is denied
- Provide a medical necessity letter
- Request a benefit exception
- Request an external review
- Inform patient of potential next steps, including benefit exception request, formal insurer complaint, regulatory complaint.
If **urgent** care is denied
- Request an expedited review
If the peer does not have relevant clinical experience
- Request an immediate review with a competent peer
- File a formal complaint with the insurer
- File a grievance with NCQA and URAC (accreditation organizations for health plans)
Document your clinical decisions
If the peer is unprofessional
- File a formal complaint with the insurer
- File a complaint with the state and/or federal regulator
- File a grievance with NCQA and URAC (accreditation organizations for health plans)
What “rules” apply to peer-to-peer reviews?
Peer-to-peer reviews may have specific requirements specified by state law and regulations, federal law and regulations, insurance company “Code of Conduct,” “Code of Ethics,” accreditation agencies, insurance policies, and otherwise. There may be meaningful variability in these requirements, even within any given payer (e.g., across specific employer plans).
Below are common expectations for the proper conduct of peer-to-peer reviews that may be helpful.
- Peer reviewer must have appropriate clinical competence:
- Peer reviewer must be timely available to the treating clinician based on patient requirements:
- Peer reviewer must comply with the insurer/payer’s Code of Conduct and the health insurance plan of the patient;
- Authorization by a peer reviewer of an adverse determination (i.e., denial of coverage) without sufficient review and consideration of medical records is not permitted.
- Peer-to-peer review transcripts and supporting documents are to be included in the patient claims file for potential reference in appeals or other dispute resolution processes.
Download one-page summary of “rules” for peer-to-peer reviews
Suggestions? Stories from peer-to-peer reviews?
We welcome your suggestions and stories from peer-to-peer reviews that might be helpful to improving our resources.
Email suggestions and stories to provider@covermymentalhealth.com, though please do not include any patient personal health information. Thanks.
Summary of resources and best practices
Clinicians treating patients with mental health and/or substance use disorders may encounter required discussions with health insurer “peers” in connection with (a) prior authorizations, (b) progress check-ins, (c) medical necessity determinations, and (d) similar “reviews,” quality oversight, or appeals.
The resources below support preparation and patient advocacy during peer-to-reviews:
Five suggestions for peer-to-peer reviews (a short video)
(in development)
