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.

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The 5th “R” of Personalized Medicine: Right Cost

A recent article published in Managed Care highlights the flood of new diagnostic forces and why insurers are starting to ramp up prior authorization and utilization review. Today’s torrent of information around genetic and molecular markers for disease has outstripped the ability of physicians, health plans, and patients to know exactly what every new test means.  Sometimes clinical labs introduce up to 10 new genetic lab tests per week. This number means that many plans are deciding to adopt prior authorization for genetic tests.

Hiring utilization management vendors is one way that health plans are seeking to control the ballooning cost of genetic and molecular testing. The complexity of such tests involves much more than a yes-or-no answer, says Lon Castle, MD, chief of molecular genetics and personalized medicine at eviCore healthcare.  Genetic and molecular testing is the fastest growing segment of the lab market, and Castle says the best estimates are that it will generate $11 billion in sales this year for lab companies “and that’s just molecular and genetic tests.”

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Leading Technology-Enabled Medical Benefit Management Company eviCore healthcare Acquires QPID Health

Combined entity will support healthcare’s shift to value-based care with advanced analytics, software and services to support payers, hospitals, physicians and patients

BLUFFTON, SC – February 26, 2016 – eviCore healthcare, a company committed to enabling better outcomes for patients, payers and providers through advanced medical benefits management, today announced that it has acquired Boston-based QPID Health.

QPID Health, a Partners HealthCare spin-out in late 2012, has a history of innovative partnerships with leading health systems, helping providers achieve their care quality and cost reduction goals with sophisticated analytical software that generates actionable information and clinical insights from patient records.

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The Benefits of Web Authorization

Did you know that most providers are already saving time submitting prior authorization requests online? We have been listening to you and have incorporated a number of enhancements that will streamline your online experience, allowing you to go from request to approval faster!

Benefits of using the web authorization service:

1) Save time! Web authorization requests take 1 minute 30 seconds on average. Phone authorization requests take 12 minutes on average.



2) 24/7 access! You can access the web authorization service at any time, on any day. Phone authorizations have to be requested during business hours.

3) Save your progress! Need to step away? Need to obtain additional information? Save your authorization request progress and come back to it.

4) View and print authorization information! Authorization information and number are at the tips of your fingers, so you can print them at your convenience.

5) Other online features include the ability to access clinical criteria, look up member eligibility, and upload additional clinical information to an existing case.

For more information visit or email us at

Intelligent Healthcare: Managing Low Back Pain at eviCore

One word: Inspired.

I was watching a TEDMED talk the other day…you know, the short video presentations where the speaker tells a story? This particular talk was about cleaning water that was polluted, as told by Peter Janicki. During the video, pictures of shanty towns littered with trash were situated near the water sources. What does cleaning water have to do with helping our clients and their members, or patients, or your husband or mother, get better treatment for their lower back pain? Sit tight. I will get to that.

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For more than seven years, eviCore has been managing high-cost musculoskeletal procedures in the form of hi-tech imaging, pain procedures, and spinal surgeries related to chronic and sometimes debilitating low back pain. We do this well and it is a good thing that we do. About 20% of a given commercial health plan’s member population have a musculoskeletal procedure annually. The cost of those members participating in musculoskeletal procedures is approximately 20% of the commercial health plan’s total healthcare costs. Moreover, one member in eight will miss work due to painful musculoskeletal issues, resulting in decreased productivity.

Back to the water…

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