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Health plans employ prior authorization (PA) and other forms of utilization management (UM) to control access to certain treatments in a bid to cut health care spending. The AMA has achieved recent wins in 5 critical areas for physicians.
The insurance peer-to-peer review (P2P) is one important strategy used to avoid or reduce claim denials, and therefore, prevent revenue leakage. What can healthcare providers do if their requests for prior authorization are denied for lack of medical necessity or other reasons by an insurer?
Peer to Peer (or P2P) is essentially the patient’s doctor justifying a patient’s medical order, prescription, or inpatient status to the insurance company’s medical director. These interactions occur when the payer denies a claim according to their own internal policies and requirements.
Prior authorization information and forms for providers. Submit a new prior auth, get prescription requirements, or submit case updates for specialties.
Peer-to-peer review This is a process in which an ordering physician discusses the need for a procedure or drug with another physician who works for the payer in order to obtain a prior authorization approval or appeal a previously denied PA.
In this third installment of an AMA series on fixing prior auth, we take a look at the need to overhaul the so-called peer-to-peer process that insurance companies use to delay and deny prior authorization approvals.
Prior authorization is usually the first step to ensuring that patients have the medical insurance to provide payment for whatever medical procedure or medication they need. It simply functions as a means of confirming a patient's eligibility for specific treatment without stating how much coverage.
This document explains what providers need to do to request a peer-to-peer review with a Blue Cross Blue Shield of Michigan or Blue Care Network medical director about services for which a prior authorization request has been denied by Blue Cross or BCN.
Leverage a payer’s peer-to-peer process. Speaking with the insurer’s medical director or other physician available to speak with physicians about prior authorization issues can clear up...
What is a peer-to-peer process or “P2P”? The peer-to-peer process—often referred to as a “P2P”—provides an opportunity for providers to discuss criteria used to make specific coverage determinations.