Tip #1: How can I Avoid Peer-to-Peer Conversations?
Before becoming a Medical Director for EviCore healthcare seven years ago, I had the privilege of serving for 30 years as a primary-care internist in Nashville, Tennessee. My last few years of private practice were during those early years of prior authorization, when only a few insurance plans required approval for advanced imaging studies (CT scans, MRI scans, PET scans, and nuclear cardiac studies). In my first few years as a Medical Director, I was surprised at how many requested imaging studies were being denied — even for what appeared to be routine studies — and how often peer-to-peer (P2P) phone conversations took place. Since then, I have been committed to helping other providers avoid peer-to-peers by educating them on ways to avoid denials.
One discovery I made early in my new career as Medical Director concerned the outstanding quality and usefulness of EviCore's evidence-based guidelines. My earliest reaction was, “Gee," I thought, "I wish I had known of these guidelines all those years when I was practicing medicine… how helpful they would have been!" EviCore's guidelines are concise, easy to follow, and updated yearly, and by applying them, you can quickly identify the best imaging study based on your patient's clinical presentation.
They are available, accessible, and free, and can be easily transferred (as PDF files) from EviCore's website to any provider's desktop. Some guidelines (such as the Abdomen chapter) are conveniently organized by body location and symptoms, and are structured exactly as providers are trained to think. For example, subchapters are labeled: Right upper quadrant pain r/o gallstones, Flank pain r/o kidney stones, Left lower quadrant pain r/o diverticulitis, and Right lower quadrant pain r/o appendicitis.
EviCore's guidelines are fully referenced and are based on those carefully constructed guidelines created by national medical organizations such as the American College of Physicians, American College of Radiology Appropriateness Criteria, and American College of Cardiology.
During P2P phone calls, EviCore Medical Directors often suggest to providers that they download the EviCore guidelines and use them whenever there is uncertainty as to the best imaging study to request. By referring to these guidelines, not only can you contribute to practicing evidence-based, high-value care, but you will also help reduce the number of imaging denials, appeals, and peer-to-peer calls.
Find the guidelines on the EviCore website, under Resources - Providers - Cardiovascular & Radiology.
Take Home Point #1:
Check out EviCore's guidelines, paste them on your desktop, and refer to them whenever you are uncertain about the best imaging study to request.
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.