My surgery has been rescheduled for the 2nd time. Now it's Feb 10. As I had mentioned before, I am waiting this 'vendor' of the BCBS insurance company to respond to my surgeon's request to appeal their initial denial for authorization of the knee surgery. This vendor is called TurningPoint Health. So, I did a little research on this outfit and saw what the requirements were to be a reviewer of "peer to peer" cases like mine. I'm really just writing all this for myself for reference.
I found on their website a job listing for a "Clinical Peer to Peer Reviewer" for this company. (This specific job was for peer to peer evaluator for spine). I was shocked. These are the qualifications of someone that represents my insurance company, who must decide on my medical treatment, and is supposedly an 'expert peer' that will evaluate my case with my world renown surgeon who is a specialist in the procedure that I need. Here are the basic qualifications for a "Clinical Peer to Peer Reviewer" for the TurningPoint Health vendor:
Education, Experience and Licensure:
• Master's Degree as a Nurse Practitioner or Physician Assistant
• A Board certification as Primary Care and or Acute Care Nurse Practitioner or Board certification as Physician Assistant; Active State Licensure
• Minimum of 5 years' experience.
Un-FN-believeable. Not a physician. Not even any specific training in surgery, orthopedics, research, or most importantly, not any specifics related to spine!
Here's another health company and their peer review requirements:
Acentra Health must have qualified peer reviewers who meet the following federal regulations: Must be a doctor of medicine, osteopathy, dentistry, podiatry, or optometry, or another individual who is authorized under Federal or State law to practice medicine, surgery, osteopathy, dentistry, podiatry, or optometry Have a current state license. Are board-certified. Active practice means that the physician usually practices (on a routine basis) a minimum of 20 hours per week.
"... the reviewing P2P physician must have the clinical expertise to treat the medical condition or disease under review and have knowledge of the current, evidence-based clinical guidelines and novel treatments."
It seems to be the law: § 476.98 Reviewer qualifications and participation. LII Electronic Code of Federal Regulations (e-CFR) Title 42—Public Health. Subpart C—Review Responsibilities of Quality Improvement Organizations (QIOs)
42 CFR § 476.98 - Reviewer qualifications and participation. (a) Peer review by physician. (1) Except as provided in paragraph (a)(2) of this section, each person who makes an initial denial determination about services furnished or proposed to be furnished by a licensed doctor of medicine or osteopathy or by a doctor of dentistry must be respectively another licensed doctor of medicine or osteopathy or of dentistry in the QIO area.
In case of a denial, this sure will make my case for an external review or lawsuit pretty strong. Are you kidding me? A masters degreed nurse practitioner telling an expert surgeon what he should or should not be doing? This is f-ing crazy.
There was a article about insurance companies using AI tools to review claims and those who employ them have a higher denial rate.
ReplyDeleteMedical Director/ Physician Reviewer- Spine Surgery (IN, MS, NV, GA, AZ)
DeleteRoles and Responsibilities:
.
"Reviewing cases which were not approved by pre-review screening process or by the initial Clinical Reviewer’s algorithm." (indicates AI)
"Conducting a peer-to-peer consultation for all determinations which do not meet the criteria for approval.
Rendering an adverse determination, along with justification statements for the adverse determination letter." (Seems to show that their job is deny)
The insurance companies don't care if you are an elite athlete or even a weekend warrior. They look for the cheapest fix to get you back to doing normal daily activities. They think if you're a 65-year-old man you should not be running anyway. They think you should be playing golf maybe bowling walking in the park playing with grandchildren pretty much waiting to die.
ReplyDeleteVery true. Well said.
DeleteAre you definitely laying out the money if you need to do this totally out of pocket?
ReplyDeleteYes, thats the plan. Probably likely the case since I heard my peer to peer was scheduled this morning and if it were successful, I would have heard by now. Probably waiting for the denial letter so they can quote me a cash price. The biggest benefit for out-of-network is not the 60% coverage, it's the out of pocket limit that is $7200. That doesn't apply if I pay after a denial.
DeleteHope it works for you.
ReplyDelete