Tip #4: "How can I Avoid Peer-to-Peer Phone Calls?"
Before becoming a medical director 8 years ago, I practiced general internal medicine in a solo practice in Nashville, Tennessee. My first realization upon making the transition to a medical director was how useful EviCore's evidence-based guidelines were. I remember thinking “Gee, I wish I had known of these guidelines all those years when I was practicing medicine…How helpful they would have been!"
Not only are EviCore's evidence-based guidelines well organized and updated annually, they are also concise, easy to read, and well-referenced. That first year as a medical director, I told one of my associates from my prior life in clinical practice about the guidelines and how useful they could be in avoiding denials and peer-to-peer calls. Once he discovered how valuable they were, he told me that he felt he'd found "the keys to the castle" and remarked that they were truly EviCore's "best kept secret!"
In fact, EviCore's guidelines are not a secret at all. They are free to access and download any time from EviCore's website. Since the guidelines are published in PDF, you can save them to your own system for reference at any time. Uncertain about the best imaging study for your patient with abdominal problem? Is it an ultrasound? Or is it a CT or an MRI or an MRCP? For periumbilical pain, should you request imaging of the abdomen, or pelvis, or both? If an ultrasound shows a liver mass, should you request a noncontrasted CT, a contrast CT, or both? EviCore's guidelines are a valuable reference whenever you need direction on the most clinically appropriate and cost-effective next step in treating your patient.
One question I often get asked during peer-to-peer calls is what sources we use for our guidelines. We use a rigorous process of accumulating and assessing the best available evidence, in accordance with the standards of our accreditation agencies (URAC and NCQA). In short, each chapter in the EviCore guidelines reflects the most current and authoritative evidence-based recommendations created by well-respected national organizations and made available to the public. Primary care and specialty organizations such as the American College of Physicians, American Academy of Family Medicine, American College of Cardiology, American College of Radiology, NCCN, and American Academy of Sleep Medicine create thousands of pages of guidelines and appropriateness criteria that cover diagnosis and treatment. EviCore extracts from those guidelines the criteria that deals specifically with imaging and compresses national guidelines into a single document of less than a thousand pages. This allows the EviCore guidelines to be a very concise reference that providers can access while in the process of seeing patients. While it is unlikely that you will need to look at guidelines with every requested imaging study, it is comforting to know they are available in cases of uncertainty.
I often invite providers to download EviCore's guidelines and use them whenever they wish. Some physicians tell me they usually refer to UpToDate, or another well-respected reference. Some tell me they just call a radiology colleague whenever they are uncertain. I invite them to compare these methods with using EviCore's guidelines and then decide which is faster and more convenient.
Take Home Point #4:
Not only are EviCore's guidelines no secret, they are your readily available “keys to the castle." Download them, keep them on your desktop, and refer to them whenever you are uncertain. Use them when you want to get prior authorization “right out of the gate" and avoid denials and peer-to-peers.
The path to the EviCore guidelines on EviCore.com:
www.evicore.com - Clinical Guidelines and Forms - Clinical Guidelines - Cardiology & Radiology - PDFs
Author: Robert L. Neaderthal, M.D.
Robert L. Neaderthal, M.D. has been a medical director at EviCore healthcare for 8 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.
For more tips on how to avoid peer-to-peer phone calls, read our other tips as part of the "How Can I Avoid Peer-to-Peer Phone Calls" series here. For questions regarding this topic, please email onlineinfo@evicore.com.