Does anyone know how to go about a peer to peer review My state insurance is...

%d comments
  • Hi Chris Chakonas - I'm not sure that there are too many people who have experienced this. Michael Rawlins, may be a resource to you - have you seen his whole insurance appeal which he generously shared for us in files? I'm wondering if you can call the Ombudsman at the local hospital and ask if they can guide you to some information? This may be a project that you will have to undertake on your own and teach us!

  • Any doctor who believes a particular treatment is medically necessary should be willing to do a peer-to-peer phone call to convince the insurance to cover it. The doctor just has to know what he's talking about and be able to explain it to another doctor who works for the insurance company. He doesn't have to try to dumb it down for a lay person to be able to understand. If he has a good understanding of the science involved and the relevant studies, it shouldn't be a big deal for your doctor. The peer-to-peer is considered to be the standard first level of appeal on a rejected claim.

    When my doctor did it to convince my insurance to cover RT, it didn't work, so I had to submit my own second-level appeal.

  • So this doctor could be a doctor that I haven't seen personally yet,nbut who believes a treatment will help my personal self?

  • Hmmm. I do have some billing/financial people resources from my prior job, which was an Ombudsman role, that may be able to assist me. I think the main concern is the fee and payment for all. Thank you!

  • He might surprise you and be helpful, if not start looking for a new doctor and go prepared with what you've learned from DDSG.

  • Well I have everything to gain by asking him, since he has seen my progression through all of this. I am open to receiving his cooperation to honor doing a peer to peer review and a very positive outcome for my highest good. It's normally so long of a wait to get an appointment, so I am setting an intention for either talking with him over the phone this week or seeing him in person to discuss a peer to peer review. :)

  • Sounds like a good plan Chris! Best of luck to you.

  • Your doctor has to do the peer to peer. As a physician it is usually a complete waste of our time, but a necessary evil caused by insurance companies denying everything we order ( sometimes seemingly randomly).

  • Thank you Dr. P. For taking time out of your busy schedule. I appreciate your expert advice. I am seeking this peer to peer review to allow me to travel out of state to see you for a consult and treatment. I am positive and hopeful that insurance will act in favor of me, despite the fact that it is a state assisted insurance.

  • I had an exam from the radiation oncologist, Dr. Sinopoli. He determined that radiation therapy was medically necessary for me. His office submitted a pre-authorization request for the treatment. The insurance company rejected the pre-authorization, saying that the treatment is experimental. Doctor Sinopoli did a peer-to-peer phone call with the doctor from the insurance company to try to convince him to authorize the treatment.

    When that failed, I submitted my own written appeal with piles of documentation showing that RT isn't experimental. They approved it and I got treatment.

  • I had tried for 2 years to convince primary doctors and hand surgeons to refer me to Dr Sinopoli but no one would do it. I had to change insurance in order to be able to self-refer to get in to see Dr Sinopoli.

  • You can also use the power of your elected congresswoman to out pressure on your insurance company.

  • From reading this thread, I have a vague sense of what a "peer-to-peer review" might be, but could someone briefly explain what it is?

  • I pasted BCBS description below

  • Thank you Leslie for this link. Very grateful for it. At this time Dr. P's Office informed me that they do not accept my insurance, so I am not sure where to go from here in this moment. :(

  • I just PMd you.

  • Chris, I would also seek assistance from your state's elected insurance commissioner.

  • According to my insurance, I have to follow the red tape guideline procedures. Peer to peer is not the first route. Request for referral from current doctor is the first step in seeking a doctor out of network. If denied, which usually it is. Time frame for decision of this is 48 hours. Then a letter is sent out within 30 days notifying me that I can appeal in person to the medical director and a panel of whom else I am not certain. If that's denied, which it may be because there are doctors within the network that perform said procedures. Then I'll receive another letter within 30 days informing me I can make my appeal to the state. Seems like a lot of red tape process. Meanwhile my hands continue to contract, preventing me from returning to the work force In my career because I need my hands to do my job. I'd love to just jump over all these hurdles and go straight to the top for an answer. Seems like that would save the state a lot of money in the long run.

  • It is odd to me that your insurance company requests that you take all this time doing their "process" before contacting the state insurance commissioner. You might call the insurance commissioner's office and inquire about that process requirement. I would. They are there to protect the consumer from unfair insurance company practices.

  • Good idea...Thank you! They are on my list to call first tomorrow.