Prior-Auth/Utilization Review Side Gig

[wcinewbie]

I came across a potential side gig reviewing prior authorizations and utilization.  Do any of you have experience with this type of work?  Is there special insurance that needs to be carried for this type of work?  What should I look out for?  Last thing I want to happen is to be involved with a sensationalized story some day about a patient who was denied medical treatment for some administrative reason.  The type of cases I would review would be within my specialty.

[gap55u]

I usually get peer to peers from me (primary care) to radiologists. The worst companies require callback by end of day or it’s denied. Tremendously annoying as much of the time they say either “I hear you but my insurance protocol mandates...” or they agree once I take the time to actually call them. eg doctor’s time =the filter to deny care. A few times I got the “hey the member’s plan doesn’t even require approval but we do this to let you know our protocol”. I especially enjoy that waste of my time.

You might imagine the 4 letter words your fellow physicians will use, bottom line. I have also taken to getting name and license number on any denial. It’s always interesting how this can change the equation. . So I f you are a radiologist proceed with caution.

[runfast00]

On peer-to-peer I always ask for the spelling of the last name, NPI number, the physician speciality and if they are licensed to practice in my state.  I tell them that information will go in the patient note.

I also have put them on speaker phone in the patient room and inform them that under my state regulation they may have initiated a doctor patient relationship by talking with the patient.

 

I know that this is not the information you are looking for, but for this primary care physician I will always go to bat for my patient and to defend me from a malpractice risk of missing a diagnosis.

 

I think peer to peer is generally a waste of my time (and it is designed that way by insurance companies).  Please think twice.

[snowcanyon]

How much are they paying you? Is there peer-to-peer?

[Hank]

Is this really how you want to earn your 30 pieces of silver?

[okayplayer]

runfast00 is my new hero.

[DCdoc]

I can’t imagine doing this. If no physicians agreed to do so, peer to peer would vanish. As it stands, some physicians are willing to accept nominal compensation to be a roadblock to patient care.

[redsand]

runfast00 wrote:

On peer-to-peer I always ask for the spelling of the last name, NPI number, the physician speciality and if they are licensed to practice in my state. I tell them that information will go in the patient note. I also have put them on speaker phone in the patient room and inform them that under my state regulation they may have initiated a doctor patient relationship by talking with the patient.

Click to expand...

I have never thought of this. Wow.

Honestly, I am never in the room with a patient when the situation of doing a peer-to-peer comes up (though I could see it work if a patient was an inpatient, and the peer-to-peer was about whether to authorize a continued hospital stay). Such things come up for me many days after an outpatient visit and relate to coverage for tests I think are medically indicated.

[runfast00]

I practice in a small town and often the wait time on hold for peer to peer is 30 minutes so I will call the patient and have them come up to the office

Also if they ask if I did some random physician exam test I will do it while they are waiting on the phone


It has really dropped my denial rate

[bonebrokemefix]

That was my question, what are the logistics of getting the pt to the office at the exact time a conversation happens. I would think there would be a way to conference the patient into the phone call though.

[shantster]

runfast00 wrote:

I practice in a small town and often the wait time on hold for peer to peer is 30 minutes so I will call the patient and have them come up to the office

Also if they ask if I did some random physician exam test I will do it while they are waiting on the phone

It has really dropped my denial rate

Click to expand...

That's also a great way to take get paid for the time spent dealing with these obnoxious calls.

[[email protected]]

Many of these so called peer to peer review MD's are paid by the insurance companies who are often trying the deny care. I treat many many patients in the worker's compensation arena that require peer to peer review calls. These are outright obstructionist mechanisms created by the insurance companies in order to deny care. Docs will call me at the end of the day after I've left the office,  and document that since I wasn't available when they called, they decided to deny approving the test (e.g. MRI). If they do call in the morning when I'm in a patient's room, some will create an arbitrary deadline before denying it (e.g. "if you don't call back in 2 hours, we will deny this case"). When I do speak to them, many have not even read the chart and will even ask me to present the case to them as if I was a medical student!

Many peer to peer docs are one of the ff extremes:

1. relatively  young their careers , naive and who don't understand the "business" of medicine and greed of insurance companies

2. Older MD's , close to retirement or post retirement who don't "care" and just want some extra cash flow coming in