Clinical Context Matters: Maximizing the Impact of Peer-to-Peer Reviews

For concurrent denial determinations, the peer-to-peer medical review process often offers the best opportunity to get a case mediated before the overall impact to revenue becomes substantial: therefore, maximizing this brief window of opportunity is crucial. With only one shot, an effective peer-to-peer review process requires three things: the right data, the right format, and the right approach.

The Right Data

When approaching a peer review, having the right data on the patient and situation – ranging from presentation date, medical history, chief complaints, history of present illness, pertinent physical or diagnostic findings, concern of the treating physician, respective treatment plan, and support – makes the process far more efficient – especially if it clearly articulates and memorializes the status determination, as it was made.

The Right Format

Since much of this information is interspersed throughout the electronic medical record or other notes, technology that captures each of these relevant data points and crafts a clinical picture is invaluable for equipping the physician advisor during the review. The right format – a narrative of medical necessity – ensures data that could potentially be lost or overlooked becomes meaningful and persuasive. In these situations, the right “whole” is often more than the sum of its parts.

The Right Approach

The optimal approach to the peer-to-peer review process achieves “widely accepted compliance through concordance.” This concept of concordance demonstrates alignment among the critical components of clinical case review. Simply listing components – severity of illness, documented concern of the treating physician, and intensity of service – but not demonstrating how they are aligned is not concordance, and as a result, not a compliant process. If all components demonstrate alignment with one another, then concordance is satisfied, the process is compliant, and the resultant inpatient or outpatient status recommendation will stand on its own merit.

Context That Compels Success

As the ultimate peer-to-peer decision is dependent on the information presented, generating a clinical narrative automatically helps your physicians capture all relevant data points, in a clear and concise format. Despite most organizations’ efforts to overturn denials early, the peer-to-peer review process often goes unsupported and transforms into a conflict conversation based on opinion, not data. The impact that technology provides for supporting these conversations can be substantial.

Find out how Xsolis helps its partners overturn more than 50% of their Peer-to-Peer reviews by scheduling a demo today.