Tips on the Insurance Peer-to-Peer Process in Patient Care

Tips on the Insurance Peer-to-Peer Process in Patient Care Posted By:
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Medical care has evolved significantly since I started practicing almost 18 years ago: From paper charts to electronic records, and from local pharmacies to large mail-order pharmacies. However, one thing that has remained rather constant and that significantly impacts the care we can deliver are insurance companies and their policies. It has become abundantly clear to many of us in healthcare that we are bound by what we do and don't document; that what we believe is best for the patient may not always be what the insurance company believes the patient needs or is willing to cover. Insurance technicalities are a fine line that we all have to walk in order to help our patients get the care they need and deserve.

One thing I have learned over the past 18 years is that many insurance companies contract out the medical management of benefits, such as diagnostic imaging and other procedures, to companies like eviCore and AIM. The contracted company creates criteria and guidelines that the insurance company follows, and that is the basis for how they decide if a patient is covered for a procedure or not. Learning that these guidelines existed allowed me to realize the "why" behind things not getting approved. I now know I can review those guidelines prior to ordering something so that I am not beating my head against the wall trying to get something approved that just doesn't fit their benefit mold. For example, I have learned that sometimes getting an x-ray first will land me at least 3 steps ahead in getting the MRI that I really need covered for my patient.

I still have plenty of drawn out conversations with the medical directors at these companies, but at least with the knowledge of these guidelines I am more prepared for "battle." Ultimately, I have learned that these medical directors are not an evil force, but just the messengers for the corporate managers of the insurance company.

I encourage all healthcare professionals to learn more about these criteria and guidelines so you too can avoid the frustration of repeatedly fighting the system. As I mentioned, I still have plenty of battles with insurance companies, but with the knowledge of these guidelines I am better able to win the battles and get the testing I need for my patients approved.

For your reference, here are the links to eviCore and AIM, 2 of the medical benefits managers commonly used by BCBS, Aetna, United, and Cigna.


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Filed under: Health Policy and Trends , Practice Management/Career

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