Readers of this blog will know that we’ve been posting a series of tips on how to minimize the complexity of the prior authorization system. In our series of posts under the heading “How to avoid peer-to-peers,” we’ve been coaching you on how to best prepare before you initiate the prior authorization process.
So now you might be thinking, “what’s up with this post?”
Trust us —it’s not a contradiction. Our primary goal has always been to make sure that each patient gets the right treatment or test and at the same time we want to simplify and streamline prior authorizations, So our commitment to modernizing prior authorization includes the proviso that it will not compromise our focus on that primary goal.
What is the purpose of a peer-to-peer conversation with one of our physicians? It’s precisely to ensure that the evidence-based guidelines that your medical staff applies every day are discussed in relation to your particular patient, when that is deemed advisable. So, having said we want you to avoid unnecessary peer to peers, in the event one is required, here are the top three reasons why you should love peer-to-peer conversations:
1. They’re educational.
Each participant will learn something from a peer to peer. The eviCore physician will get a better understanding of the specific patient circumstances and rationale behind the order. The ordering physician might learn about recent studies in the field and how an alternative approach might be more beneficial. New evidence, research, and study findings emerge nearly every single day, and these sometimes influence our guidance on how patients should be treated. This is one of the key reasons why eviCore offers peer-to-peer conversations—to help educate providers on up-to-date information that will promote better outcomes for the patients’ health.
2. They facilitate provider collaboration.
eviCore recognizes that there is an actual patient associated with each case, and that’s why we assign a physician to review each one. Peer-to-peer conversations allow clinicians to have a discussion about that patient. The ordering provider provides the patient’s medical history, symptoms, and examination results to the conversation, and the eviCore physician is able to lend his/her own professional experience, along with easy access to and knowledge of the most current clinical guidelines.
In combination, eviCore’s physicians bring expertise in all the specialties related to our solutions, and are licensed in every state of the union. Our policy is that when a requesting provider asks to speak to a like-specialty reviewer, eviCore makes such a person available in every case. The requesting provider will gain access to an eviCore specialist who has been rigorously trained in appropriate utilization and is knowledgeable in the specialty and understands the appropriate patterns of diagnosis and treatment.
3. They explain the application of the clinical guidelines.
The eviCore clinical guidelines reflect various clinical support content, such as: the risk factors for conditions, diagnostic criteria, prognostics with and without treatment, the benefits and risks of various treatment options, resources associated with different diagnostic or treatment options, and patients’ experiences of the options.
In addition, during a peer-to-peer conversation our physicians, who are well-versed in the clinical guidelines, can provide background information as to why a case is being reviewed or why an alternative treatment recommendation was made.
To summarize: yes, peer-to-peer phone calls take time out of your extremely busy day. And we understand that usually they are something that you would prefer to avoid. But should you find yourself on a peer-to-peer phone call, remember that it can offer real benefits—to your case analysis as well as to your understanding of the specialty—so your time will likely be well spent.