A Peer? Nowhere Near
By Joey Berlin Texas Medicine September 2017

Texas Physicians Often Find Utilization Reviewers' Credentials Lacking

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The Obstacle Course — September 2017

Tex Med. 2017;113(9):27-31.

By Joey Berlin
Associate Editor

They're called peer-to-peer calls, but Houston urologist John Bertini, MD, has another name that he thinks is more apt: "nuisance calls."

Dr. Bertini has set out on the prior-authorization obstacle course many times, so he knows what an insurer requires for physicians to get a procedure or medication approved. He dials what's usually an 800 number and eventually reaches a utilization review agent's chosen "peer," with whom he must talk to justify the test he's ordered.

Talking to a true peer, he says, would mean talking to a physician in the same or a similar specialty who's licensed in Texas. In Dr. Bertini's case, talking to another Texas urologist would suffice.

"But no," he says. "I get some pediatric endocrinologist who's calling from their car in Sacramento, Calif., and doesn't even know what urodynamics is, and I have to explain it to them."

For Dr. Bertini, peer-to-peer calls have never led to a coverage denial, but they have led to bureaucracy and wasted time. That makes a difference, even if the result isn't a denial ― and, sometimes, Texas physicians get denied.

Dr. Bertini says his impression is that the calls are "an annoyance the insurance companies create, hoping that the doctor will say, 'Oh, screw it, I'm not going to call,' and just cancel that test. [They're] thinking, 'If we create enough impediments, [the doctor will] just capitulate and give up.'"

He says physician problems with peer-to-peer conversations have picked up in the past year, and plenty of other doctors are reporting their own problems with the calls. The Texas Medical Association is continuing efforts to improve the peer-to-peer system, including supporting unsuccessful legislation this year that would have put an end to reviews with physicians not licensed in Texas.

Austin internist Ghassan Salman, MD, chair of TMA's Council on Health Care Quality, says health plans have an opportunity to improve the situation for patients and their physicians.

"From the insurance perspective, they can improve their processes … to be more focused on the issue at hand and do what's best for the patient. And what I mean by that is having a reviewer that's as [familiar] as possible [with] the problem that's being addressed."

Any Specialty, Any State

Health plans regulated by the Texas Department of Insurance (TDI) must give a practitioner a chance to explain to a physician why a treatment is medically necessary or appropriate before a utilization review agent denies the request. Texas laws and TDI regulations don't expressly state that a physician who handles a peer-to-peer call has to be of the same or a similar specialty. The Texas Insurance Code only requires that the patient's physician gets "a reasonable opportunity to discuss with a physician the patient's treatment plan and the clinical basis for the agent's determination."

Chris Henderson, executive director of payer and public health relations for Texas Oncology, says peer-to-peer calls are "really becoming an increasing trend in what oncologists are dealing with." He says Texas Oncology has had recent difficulties with calls involving its radiation oncologists. It's "something I'm hearing about from my docs on a pretty regular basis now, especially when they don't have a good interaction, where the [reviewing] physician is unfamiliar with the modality," Mr. Henderson said.

The requirements do change once an insurer denies an appeal and the case moves to a second appeal. At that point, the patient's physician has 10 working days to state in writing why there's good cause for a practitioner of a particular specialty to review the case. If a physician successfully makes that case, a practitioner of the same or a similar specialty will have 15 working days to review the treatment request. An insurer's expedited appeal process ― such as for a denial of emergency care or continued hospitalization ― also must include a procedure for review by a same-or-similar-specialty reviewer.

TDI regulations also don't specifically mandate that the utilization reviewer be licensed in Texas, except for workers' compensation cases. However, the Texas Medical Board says utilization review "requires a Texas medical license or provider acting within the scope of their license under the direction of a Texas physician." It also says utilization reviews must be in compliance with Texas insurance law.

If the case goes past the insurer's appeal process to an independent medical review, the independent review organization to which TDI assigns the case must perform its primary functions in Texas and must have a Texas office (See "A Fresh Set of Eyes.")

"Very Suspicious"

Houston internist Lisa Ehrlich, MD, president of the Harris County Medical Society, says prior authorization of medications usually doesn't require any phone time from her. "Although that does take up a considerable amount of staff time," she said. For tests she has to order, such as MRIs or CT scans, Dr. Ehrlich has to talk to the reviewer herself.

"But I'm talking to a doctor who obviously hasn't examined the patient, doesn't know the patient, and they're just going down a checklist, basically," she said.

If a reviewer denies a test Dr. Ehrlich thinks is necessary, "then they're actually practicing medicine." She estimates that her requests get approved 90 percent of the time. For the 10 percent that are denied, she sends a letter to the health plan to effectively tell them, "Just understand, you're practicing medicine on this patient whom you've never even seen." She says that ultimately works about half the time.

"It's pretty obvious when we're on the phone with these folks that their whole purpose is to deny the service," she said.

"There are some plans that we have to get prior authorization on 100 percent of testing, so we have to jump through a bunch of hoops [using] my staff," she said. "But there are some that are worse offenders than others that I have to get on the phone to get it covered. Those are the ones that are really aggravating because they're not looking at it going, 'Here's this study for this purpose. It seems wrong; let's find out what's going on.' They just always put it to peer-to-peer review. It just makes you very suspicious."

Texas Medicine contacted three of the state's largest health plans for comment: Aetna, Blue Cross Blue Shield of Texas, and UnitedHealthcare. Aetna said its clinical leaders who could best speak to peer-to-peer issues were unavailable, and Blue Cross declined to make anyone available for an interview. United acknowledged initial email and phone requests but did not make anyone available for an interview by press time.

"If an insurance company can deny, let's say … one in 10 [services], think of all the money they save," Dr. Bertini said. "It doesn't ensure any quality because I know more than the person I'm talking to; I'm a board-certified urologist since 1987. And I don't need to order stuff that doesn't need to be done. It's just that they've just laid down a few extra steps that involve only me, the doctor."

Physicians in scantly covered subspecialties can find themselves on the phone with a clueless reviewer. Rosa Tang, MD, says Houston only has about eight neuro-ophthalmologists, including her and two of her colleagues at Neuro-Ophthalmology of Texas. Dr. Tang says a recent peer-to-peer call was for a patient with Horner's syndrome, which typically presents with one pupil smaller than the other and a drooping eyelid. The condition may be related to a carotid artery dissection, Dr. Tang says, so she ordered a CT angiogram of the patient's head and neck. The reviewer in her peer-to-peer call ― a family physician ― denied the test, even though he didn't know what Horner syndrome was. Dr. Tang says he essentially told her that "an eye doctor has no business ordering neck x-rays."

Dr. Tang says she wouldn't need to talk to another neuro-ophthalmologist to be talking to a peer.

"In my case, a general neurologist would know what I'm talking about," she said. "Many general internists will know what Horner's is and why we need to look at the neck vessels. I just happened to have a particular doctor who didn't know what it was or didn't remember it."

But once she told the physician to give her his name so she could identify him as the treating physician who denied the procedure, Dr. Tang says the physician quickly changed his tune and gave approval.

"If these peer-reviewers want to play treating doctors by denying procedures that treating physicians deem necessary," Dr. Tang said, "then they should be named as part of the treating team and be liable for any patient bad outcome."

Looking for Legislative Action

Though he considers himself someone who doesn't like a lot of regulations, Dr. Bertini says fixing peer-to-peer problems through regs and legislation is the best solution.

"A peer-to-peer call ought to consist of a like-specialtied individual with a license to practice in our state. And then it would go away, I can tell you, because they wouldn't do it," he said. "They'd find some other way to harass us. But this thing that they do makes no sense except to be another step of obstruction."

Dr. Ehrlich agrees legislation is necessary.

"[As] an internist, for me to look and say whether someone needs a urological procedure, it'd be laughable," she said. "I'd not be qualified to do that. And in our current system, they can absolutely do this."

Mr. Henderson of Texas Oncology anticipates that the peer-to-peer problem will continue to grow. A specialty requirement, Mr. Henderson says, "seems like the right and logical thing to do, and it also would put [health plans] in check and not let them just be out there sort of smothering providers with peer-to-peer calls and other tactics that are going to end up delaying care and are inefficient use of physicians' time in the clinic.

"These tactics hurt clinic productivity," he said, "but more importantly, they can impact a physician's ability to deliver appropriate care in a timely manner."

Joey Berlin can be reached by phone at (800) 880-1300, ext. 1393, or (512) 370-1393; by fax at (512) 370-1629; or by email.


A Sizable Burden

The American Medical Association conducted a web-based survey of 1,000 practicing physicians in December for its 2016 Prior Authorization Physician Survey. Among the findings: 

  • 75% described the burden associated with prior authorizations for them and their staff as high or extremely high.
  • 46% said they and/or their staff handle more than 20 prior authorizations per week.
  • 22% said they and their staff spent more than 20 hours on prior authorizations in the past week.
  • 59% reported waiting an average of at least one business day for a prior authorization decision, including 26% who reported it took at least three business days to hear from a health plan.
  • 64% said they don't have staff members who work exclusively on prior authorizations.  


Keeping Texas Reviews in Texas

During the 2017 regular session, TMA supported legislation that addressed the problem of non-Texas-licensed physician reviewers. Senate Bill 2030 by Sen. Dawn Buckingham, MD (R-Lakeway), and House Bill 2345 by Rep. Paul Workman (R-Austin) would have required utilization review agents who use physician reviewers to use physicians licensed to practice medicine in Texas. HB 2345 made it out of the House Insurance Committee but didn't reach a floor vote. SB 2030 died after referral to the Senate Business and Commerce Committee.

September 2017 Texas Medicine Contents
Texas Medicine Main Page

Published On

August 22, 2017

Joey Berlin

Associate Editor

(512) 370-1393

Joey Berlin is associate editor of Texas Medicine. His previous work includes stints as a reporter and editor for various newspapers and publishing companies, and he’s covered everything from hard news to sports to workers’ compensation. Joey grew up in the Kansas City area and attended the University of Kansas. He lives in Austin.

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