PHYSICIAN P2P: Patient Advocacy


Physician P2P:  Patient Advocacy

By Mary Corkins

Although it is a recently recognized trend for the patient to take ownership of their own healthcare cost and utilization, physicians have increased responsibility in appropriately communicating their patients’ needs to the plan medical directors.

With the pre-service changes in Insurer processes under Obamacare, the role of the Peer-to-Peer (P2P) conference call has become a critical element in the availability of new technology or costly health services. Services are prescribed based on patient need and expectation of best opportunity for clinical benefit. During the course of seeking benefits & coverage from the patients’ Insurer, oftentimes the physician will be invited to participate in a P2P before services are approved. Historically, physicians have avoided these discussions like the proverbial plague. The common belief is that P2P is non-productive and the Insurer will deny benefits regardless.

Most practicing physicians have a very poor understanding of Insurer criteria for decision-making. They are left feeling powerless and out of their element – and therefore, disinclined to participate in P2P’s. And really, who can blame them? Physician fees have been cut substantially. They are required to maintain stronger and more robust documentation of provided care. They must maintain adequate staffing, malpractice insurance coverage, re/credentialing with Insurer networks, compliance with HIPAA regulations, relevant OIG advisories, and adherence to the Safe Harbor and Stark I & II statues. The continued overburdening of physicians with P2P’s has resulted in increased denial of services for the patient. It means fewer choices and less attractive healthcare options for all.

In our experience managing tens of thousands of cases, we’ve been able to put enough control back in the hands of the practicing physicians! Of the physicians that we support, approximately 80% now participate in the P2P’s. With educated participation in the P2P’s, our approval yield is currently running at approximately 75%.

Get to “YES” faster, and more often! Physicians…don’t be afraid! Learn from us! Here’s how you can be a better advocate for your patients.

Pursuant to the 2014 Utilization Review and Accreditation Commission (URAC),

1. Health Utilization Management Standard 10 – Initial P2P

Individuals who conduct initial clinical review:

  • Are appropriate health professionals; and

  • Possess an active professional relevant license.

2. Health Utilization Management Standards 32 – Appeal or “upon request”

Appeals considerations are conducted by health professionals who:

  • Are clinical peers;

  • Hold an active, unrestricted license to practice medicine or a health profession;

  • Are board-certified (if applicable) by:

  • A specialty board approved by the American Board of Medical Specialties (doctors of medicine); or

  • The Advisory Board of Osteopathic Specialists from the major areas of clinical services (doctors of osteopathic medicine);

  • Are in the same profession and in a similar specialty as typically manages the medical condition, procedure, or treatment as mutually deemed appropriate; and

  • Are neither the individual who made the original non-certification, nor the subordinate of such an individual.

3. Compelling, Persuasive Request for Benefits & Coverage:


  • Provide a BRIEF description of your background and specialty credentials; ask for a background statement of the credentials of the Medical Director representing the Payor

  • Re-state that you are asking for “Individual Consideration” for this patient

  • Provide specific detail on why THIS patient is in need of an intervention in order to address specific conditions/problems.

  • Provide a detailed listing of failed conservative care treatments and medications (include dosages)

  • Provide approximate number of times that you have performed this procedure

  • Provide ‘general and anecdotal’ patient response experiences, if applicable

  • Provide a comment that you discussed the patient’s recommended options for treatment AT THIS JUNCTURE, and that you and the patient BOTH agreed that this procedure provided the best opportunity for clinical improvement(s).

  • Provide a copy of FDA approval/clearance letter along with all available publications relating to device/procedure.


  • Comment on Insurance Company formal Policies and Procedures…this is about specific ‘individual consideration’

  • Make an impassioned-only plea…this should be about outcomes & evidence

  • Talk about payment levels or amounts at this point…wait until they finalize a decision.

If physicians take the time to effectively participate in the P2P process in a meaningful way, their patients are the winners. And…with appropriate expectations and understanding of the Insurer responsibilities and guidelines for decision-making, the P2Ps can actually expedite care!

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