Skip navigation

Linda Collins Blogger

Prepare for a Peer to Peer Review with an Insurance Company

Posted by Linda Collins | October 04, 2017

A Peer to Peer review may be the next step when a pre authorization denial has been received from a private insurance company. The review is typically a phone call with the medical director from the insurance company and the healthcare professional requesting the service.

Anytime a private payer denies a service, they must provide information about the appeal process. Often, the next step in requesting services is to schedule a peer to peer. If the insurance company requires the call to be with the prescribing physician, it is up to you to provide appropriate information to the doctor. The physician may request you to be involved in the call as the O&P expert.

In preparing for the call with the insurance company, take the following steps:

  • Gather the patient's medical history, current evaluations and any reports from other health care professionals corroborating the rehabilitation potential.
  • Review the Payer's Medical Coverage Policy and definition of Medical Necessity.
  • Print relevant clinical studies related to the product.

Once you have the above information, organize it for the physician participating in the peer to peer. Make sure the doctor can easily support the medical necessity and clinical efficiency of the device.

During the call, the physician and you should be prepared to:

  • Provide a brief description of your background and specialty credentials; ask for a background statement of the credentials of the Medical Director representing the payer. You may specifically ask for experience in O&P.
  • Review the payer's medical coverage policy and be prepared to point out how your requested service meets the definition of medical necessity
  • Provide the technical information about the requested products.
  • Summarize the clinical benefits of the requested product and indicate there is no equally effective device which is less costly

Taking time to prepare for the peer to peer call can result in a more positive experience and, hopefully, an over turned denial of service. 

Össur R&R

The Source for O&P Reimbursement & Regulatory News & Analysis

If you have any questions for Össur’s Reimbursement Team or about Össur’s Reimbursement Services, please contact us at [email protected]