With ongoing oversight of both the content and cost of care, clinical conversations with managed care organizations (MCOs) are the norm for health care in the United States, particularly for inpatient care. This Open Forum seeks to clarify the elements essential to successful peer reviews and to promote a collegial relationship between peer reviewers and practicing clinicians. Recommendations derive from the cumulative experiences of the authors, all of whom have spent years both in practice and in conducting reviews for MCOs. Because little has been written about how to optimize the peer-review process for the benefit of all stakeholders, especially patients (1,2), we provide a conceptual framework for the peer review process and then offer some “do’s” and “don’t’s.”
Clinicians deserve a peer reviewer who is respectful, collegial, and collaborative. Even so, the requirement to explain a patient’s care is never welcome news for a busy attending psychiatrist, because of the time involved, the possibility that payment will be denied, and the perception that a peer reviewer who has never seen the patient cannot understand the complexities of the case. Clinicians may believe that peer reviewers are looking for any rationale that is legally, if not morally, defensible to deny payment for care or that they have an incentive for doing so (neither of these perceptions is accurate).
Peer reviewers’ primary job is to help ensure the best clinical outcomes within the limits of the patient’s insurance benefits. MCOs employ reviewers with strong clinical backgrounds who use evidence-based knowledge to support best clinical practices. When both the attending psychiatrist (or the hospital’s utilization reviewer) and the peer reviewer can approach a review with these expectations, the peer-review process can be significantly less painful and may often contribute to the overall care of the patient. Both parties are bound by the same ethical guidelines and want high-quality treatment with positive outcomes.
Accredited MCOs must maintain “level of care guidelines” (LOCGs)—a set of guidelines based on medical necessity criteria for each type of care that insurance plans cover. The guidelines are easily available on Web sites or upon request. They are not a referendum on the quality of care being delivered. All MCOs have their own set of guidelines, but they are generally quite similar. LOCGs, usually updated frequently, are based in part on practice parameters and treatment recommendations from several professional organizations.
Denials of coverage are almost never about the quality of care but rather about whether the care is specifically indicated and whether the patient’s clinical presentation requires treatment in a particular setting, or at a particular level of care, when other, less restrictive (lower) levels of care are also available, clinically appropriate, and less costly overall.
Avoid a peer review in the first place
Keep your utilization reviewer informed! Unfortunately, many authorizations for care that would be routine get sent for “doc to doc” discussions because the hospital’s utilization reviewers do not provide the documented information that the MCO’s care manager needs to authorize payment. If a care manager cannot obtain the relevant information from a utilization reviewer, he or she generally refers the case for a review. Just as physicians are responsible for eliciting the relevant history for correctly diagnosing and treating a patient, the MCO’s responsibilities include obtaining the necessary clinical information to justify payment for care. A prepared utilization reviewer can help to provide the information required.
Connect the treatment plan to the reason for admission
An inpatient treatment plan generally focuses on the acute issues and symptoms leading to admission that must be addressed before discharge, rather than on long-term problems that may be treated on an outpatient basis. For example, if a patient with chronic psychosis recently stopped taking medications and decompensated, the peer reviewer may ask about related precipitants and psychosocial history, with the expectation that this information has been or will be obtained from family members, significant others, and outpatient providers. The peer reviewer may ask about various contributing factors, such as the resumption of substance use, noncompliance with outpatient appointments, acute medical issues, and significant psychosocial events or conflicts. If such factors are present, the resumption or adjustment of medications alone may not be sufficient to address all of the questions about development of a successful discharge plan or what is being done to minimize the chance of a rapid readmission.
Familiarize yourself with the LOCGs
Ultimately, the peer reviewer is responsible for applying LOCGs. However, it always helps to understand the frame of reference used. If a patient’s treatment meets the guidelines, care managers will authorize payment; otherwise, they will refer the case for review. If peer reviewers can obtain clinical justification for the requested level of care, they will authorize payment. Peer reviewers, in the course of a review, also try to elicit information about additional clinical factors that may enable a patient’s care to be covered within the outlines of the LOCGs.
Advocate for acute care when acute symptoms are present
Naturally, a patient who is at imminent risk of causing harm to self or others is in need of acute care. Peer reviewers may ask detailed questions to assess the degree of acute risk of harm: How strong was the suicidal intent? Why was the patient not successful? Was the lack of success due to “undoing” by the patient or to accidental discovery and rapid intervention by others? Did the patient leave any means in place to reverse the potential outcome?
Patients who are gravely disabled and unable to care for themselves because of an acute psychiatric condition may also need acute inpatient psychiatric care, particularly when a reversible cause of grave disability is amenable to treatment. Peer reviewers may ask for data documenting the grave disability, such as severe weight loss, dehydration, or signs of squalor in the home. Irreversible causes of grave disability generally raise questions about the need for a prolonged acute inpatient stay versus long-term custodial care.
Achieve diagnostic clarity
Although a diagnosis can never properly capture the complexity of a human being’s emotional experience, it helps explain the treatment being provided. Peer reviewers will ask for an attending psychiatrist’s own diagnosis of the patient, in addition to previous diagnoses; multiple axis I diagnoses may serve to obscure the clinical picture rather than to clarify it. Reasonable attempts to achieve greater diagnostic clarity may be a basis for continued care, although this alone might not be considered a medical necessity when such efforts can be continued at a lower level of care. Efforts may include initiating conversations with collateral providers or consultants, obtaining further history from a family member, and ordering medical evaluations or psychological or neuropsychological tests as indicated. A diagnosis of psychosis not otherwise specified, although sometimes the most accurate diagnosis on the basis of a compilation of symptoms that do not fully meet criteria for another diagnosis, begs the question of what additional information would be helpful to achieve greater diagnostic precision, particularly if it will alter the treatment course.
Although it might be difficult to determine an axis II diagnosis, which is often deferred, on the basis of a single admission in a time of crisis, greater clarity is anticipated after repeated admissions. Nonresponse to some medications may have a biologic explanation; however, a differential diagnosis that includes an axis II diagnosis may help to account for unexplained nonresponse. For example, in order to determine whether significant improvement is expectable given the current level of care or whether long-term outpatient treatment is needed, peer reviewers may ask whether a narcissistic or borderline personality disorder (or style), rather than a current manic episode, may better explain a patient’s mood instability during a time of anger or frustration.
Emphasize the prevention of readmissions
A peer reviewer’s inquiry about the therapy provided at the inpatient facility is often a question about the potential to prevent a readmission and may not reflect the expectation that such services are typically provided in an outpatient setting. For example, for patients whose readmissions are attributable to lack of adherence to an oral medication regimen, switching to an injectable medication would be a good justification for continued inpatient monitoring to help prevent future hospitalizations. Conversely, for a patient admitted frequently for suicidality, peer reviewers assume that the facility is working on treating the depression, for example, but the hospital’s utilization reviewers often do not indicate why self-harm is the chosen coping technique. The absence of more adaptive coping skills, rather than the depression itself, leads to readmissions, and thus reviewers will ask whether clinicians have addressed this skill deficit themselves or through contact with outpatient providers so that a treatment plan that addresses the cognitive issue—and not the presumed medication issue—will be implemented.
Awaiting initial symptom improvement and ensuring a safe side-effect profile are reasonable justifications for the insurance coverage of acutely ill patients. However, the clinician should explain why a less restrictive setting would not be feasible (for example, the patient is still too psychotic to comply with the regimen independently). The clinician should explain off-label uses of medications or use at sub- or supratherapeutic dosages. Thus a simple explanation can convey the necessity for a longer stay—for example, the patient experienced agitation at the usual starting dosage and needs a lower starting dosage (and a longer stay).
New incidents or data from collateral sources guide decisions about acuity and insurance coverage. Is an important change likely to happen in the next day or so that may significantly alter the patient’s clinical course? For example, is a spouse about to serve divorce papers? Is a family member about to be released from prison or acknowledge previously denied sexual abuse? Is a loved one about to confront the patient about her drinking? These kinds of life events can be expected to have a severe impact on a psychiatrically compromised patient and may justify ongoing acute treatment. Or, regarding treatment, is a psychiatric colleague in the hospital about to evaluate the patient or consult on the case and offer a second opinion? Useful additional input for challenging cases can help justify authorization for additional days.
Even though peer reviewers focus on acuity, concerns about acuity usually arise because the acute state is different from the patient’s baseline. The patient who chronically engages in self-injury but does not have a lethal intent, either on or off a psychiatric unit, is likely to be perceived by reviewers as at his or her baseline and unlikely to warrant or utilize available inpatient treatment. In the case of coverage determinations made at the time of admission, the symptoms, treatment, and behavior over the past year are relevant: patients who have not responded to multiple treatment attempts at a lower level of care may meet medical necessity criteria for ongoing care at a higher level—for example, a patient with alcohol addiction who has not stayed sober despite several partial hospitalizations may need residential treatment.
Use the peer reviewer as a data source
Where allowable by law, peer reviewers can provide data about prior episodes of care and past medication trials and information about other providers whom the patient has seen. This information may be especially helpful early in the hospitalization of patients who have been with one MCO for an extended period and of patients who are “poor historians” or when collateral sources are unavailable. Care managers can offer information about aftercare options near the patient’s home, both in and out of network, and can check availability of potential outpatient providers.
Don’t rely on the tincture of time
Although no peer reviewer would disagree that another few weeks of sobriety may be good for a patient with alcoholism or that a few more months of frontal lobe development will help an adolescent to become less impulsive, time itself is not a treatment covered by insurance plans. Instead, talk about specific, imminent interventions that you anticipate will achieve an immediate impact or help prevent relapse. For example, an adolescent with an affective disorder whose struggle with her parents triggers her affective instability may have a family meeting planned that would delay discharge but that could be seen as medically necessary as a preventive measure. Such a meeting should be scheduled in a timely way; a family meeting three days hence would be unlikely to justify payment for an otherwise stable patient to meanwhile remain on an inpatient unit.
Don’t anticipate authorizations for care that patients refuse
LOCGs stipulate that patients must be able and willing to participate in the care being offered. Although extra time is necessary for some patients to accept treatment—and lack of insight into one’s condition is an intrinsic part of some psychiatric illness—health benefit plans will generally not cover extended periods for lengthy negotiations with patients or with family members in the case of children. If the patient cannot be released before the proper care is given, clinicians should focus on the legal process necessary to provide needed care, such as obtaining a conservatorship or transferring custody. Begin the legal groundwork early.
Don’t expect authorizations for dispositional issues
Peer reviewers understand that disposition dilemmas are not the fault of the treating facility. Patients waiting for a specific sober-living environment or a custody arrangement to materialize may be authorized for an extra day or two in the hope of averting a relapse that may occur without door-to-door transition. However, acute hospitalization or residential care as a temporizing measure is not a covered insurance benefit. As with legal issues, plan early for disposition.
Don’t perceive the review as being about quality
The review process is not about the quality of care or about clinicians’ credentials or abilities. The decision-making process is always about applying the LOCGs or finding a justifiable exception to extend care. Peer reviewers do not dictate care. Although they may discuss clinical management, clinical decision making is always the responsibility and prerogative of the attending psychiatrist.
Don’t squander the appeal process
Most MCOs mandate that expedited appeals occur within 72 hours from the time they are requested. Appeals provide an opportunity to present new information or describe a compelling, imminent initiative that will clarify the diagnosis or favorably alter the patient’s course—the outcome desired by MCOs, by treating facilities, and by patients.
Ultimately, peer reviewers and treating clinicians want excellent, economically sustainable outcomes. All of us welcome input to improve the review process.