The UR "peer to peer review" scam (California) (California)

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The UR "peer to peer review" scam (California) (California)

Postby Barney5 on Wed Oct 29, 2014 12:51 pm

These are some of the scenarios I have seen:

First scenario: UR doctor leaves a message on the PTP voicemail (as they call before or after hours). The UR doctor states on the message the PTP needs to call back by noon for the patient for a peer to peer review or the request will be denied. The UR doctor does not leave a phone number to call him back.

Second scenario:UR doctor leaves a message for PTP, and states he need to call back by 2:00 pm or the request will be denied. PTP calls back the peer to peer reviewer and the secretary states the UR doctor requesting a peer to peer review is busy and he will call back. The UR doctor never calls back. The UR is denied stating PTP did not return call for additional information.

Third Scenario:UR doctor reviewer states they called PTP and left a message, but never did. The UR request is denied stating the PTP did not return the UR doctors call requesting a peer to peer review.

The failure to do the peer to peer phone call was included in these UR denials, but the UR reviewers also listed other reasons to deny the request.

Why is this behavior being allowed in our system and what can be done to stop it?

I understand not all UR doctors requesting peer to peer phone conferences with PTP are doing this, just unfortunately enough to make this system a joke.

I am attaching a comment left under a story reporter Greg Jones wrote last week about employee fraud vs medical provider fraud. This poster commented on what is going on with some Utilization Reviewers. What this person wrote is what is going on. These UR reviewers are being fraudulent every time they write they attempted to contact a PTP when they did not, every time they did not return a PTP's phone call and state the PTP failed to return their call. This is happening all the time and nothing is being done about it. Who is supposed to monitor this, the medical unit?

https://ww3.workcompcentral.com/news/st ... 8af724b295

"They fail to provide their Utilization Review doctors with adequate information to evaluate a need for medical treatment. Utilization Reviewers (representatives of the insurance company) frequently fail to recognize the need for medical treatment and fraudulently state they made efforts to contact doctors for more information."
Last edited by Barney5 on Mon Nov 10, 2014 4:21 pm, edited 2 times in total.
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Re: The UR "peer to peer review" scam (California) (California)

Postby LawAdvocate on Wed Oct 29, 2014 4:31 pm

There has to be an attempt at peer-to-peer review, if circumstances forbid that, which it appears it did here, the failure of any physician to engage in peer-to-peer review is not enough to sustain a utilization reveiw non-certification or modification. So when the UR issues, the remedy for any alleged failure to engage to peer-to-peer review is for the requesting physician to carefully review the reason the UR was non-certified. If the physician has a response that would have been clarified in the peer-to-peer review process, while the parties go through the legal mechanations of the IMR appeal, the physician can send request an informal appeal responding to what was allegedly needed or rebutting the hard evidence used to support the UR non-certification or modification.
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Re: The UR "peer to peer review" scam (California) (California)

Postby Barney5 on Wed Oct 29, 2014 8:58 pm

Thank you LawAdvocate.

The above is about three different UR scenarios that I know about personally, and was not one situation. I will modify my post above to clarify. From hearing about other situations dealing with UR peer to peer issues, it has been frustrating not only to the requesting doctors but also to injured workers who have been in this situation.

Can I ask you what you mean with there has to be an attempt at a peer to peer review and what circumstances does a UR reviewer have to initiate a peer to peer review? I assume they need additional information.In the UR denials I have read that state UR attempted to contact the requesting doctor, without a response, the UR reviewer did not state what he wanted to discuss with the doctor. From what you have written the requesting doctor can write to the UR company and inquire what information was needed while the IMR process is initiated...is this correct?
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Re: The UR "peer to peer review" scam (California) (California)

Postby vampireinthenight on Thu Oct 30, 2014 7:40 am

Why is this behavior being allowed in our system and what can be done to stop it?


If you recognize that this appeal process will result in almost no difference in outcome, why would you want to stop it? It's another requirement of the UR process that enables you to object to the report if it is not done correctly.
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Re: The UR "peer to peer review" scam (California) (California)

Postby LawAdvocate on Thu Oct 30, 2014 8:54 am

Attempt means a call was made to the physician and then the UR physician and treating physician were unable to connect. If the UR does not state what was needed in the peer-to-peer review, then the UR non-certification is based on other factors and as I stated is not based on needing any additional information to non-certify or modify the treatment. This goes back to what I said that not completing peer-to-peer review is not enough. Trust me the answer is in the UR non-certification as to why the treatment was denied, but the doctors seem clueless as to how to rebut and the number of WC physicians I see following any treatment protocols are equivalent to elusive purple glittered unicorns. The physicians shoot from the hip and rely far too much on clinical experience also making them targets for medical malpractice. The best doctors are paying attention to a diagnosis based treatment protocol and following the steps as they advance from conservative to more aggressive techniques.
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Re: The UR "peer to peer review" scam (California) (California)

Postby jpod on Thu Oct 30, 2014 9:42 am

I agree; the initial issue is being overlooked: the original request for treatment did not comply with what is required to support a treatment recommendation. Like it or not LC 4600 requires treatment to meet the standards set forth in the AD's MTUS. Peer to peer efforts are an attempt to correct that deficiency without encumberence and to give the doctor a second chance to do what should have been done initially. The doctor owes a duty to the injured worker which was not met. Peer to peer is giving the doctor a chance to rectify that situation. The scam is not with peer to peer, it lies elsewhere.
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Re: The UR "peer to peer review" scam (California) (California)

Postby Barney5 on Thu Oct 30, 2014 9:54 am

Vampireinthenight, what I would like stopped is the game playing of peer to peer reviewers who are stating they called a PTP and left a message when they did not, the UR reviewers who leave messages after hours to PTP but when PTP returns their call they are not available and never return their call. The scam is they are not truly attempting to contact these treating doctors.

LawAdvocte, I agree that many doctors are not giving the correct treatment protocol.

Thank you both for your comments.
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Re: The UR "peer to peer review" scam (California) (California)

Postby bakodoc on Sun Mar 15, 2015 12:41 am

Barney5 wrote:Vampireinthenight, what I would like stopped is the game playing of peer to peer reviewers who are stating they called a PTP and left a message when they did not, the UR reviewers who leave messages after hours to PTP but when PTP returns their call they are not available and never return their call. The scam is they are not truly attempting to contact these treating doctors.


Hello Barney, as a UR reviewer for multiple vendors in CA WC, I can positively let you know that those mal-behaviors are individual reviewers.. not the company policy. In fact, all the companies I perform reviews for are very strict about the teleconference policy. What you need to do is to contact those review companies directly and report the reviewer. It's not the system and there's no conspiracy. Just bad apples.
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Re: The UR "peer to peer review" scam (California) (California)

Postby injured7825 on Sun Mar 15, 2015 7:09 am

Not one of my UR denials does the reviewer attempt to do a peer to peer with the requesting doctor, instead they leave the peer to peer to the requesting doctor to more or less make an appointment for one after its been denied but the catch is the schedule between both the doctor and reviewer, the reviewer is available 4 hours a week? What are the odds both the doctor and reviewer will not have conflicting schedules when one only has to sets aside 4 hours a week? If this reviewer only has to set aside 4 hours a week when does he/she find time to do UR reviews?

If the requesting physician would like to discuss this determination with the reviewer, the requesting physician may contact *** at (000) 000-0000 so that a convenient time may be arranged for this discussion. All reviewers are available for at least four hours per week during normal business days from 9:00 a.m. to 5:30 p.m. PST. Additionally, please feel free to contact us should you have any additional questions regarding this claim.
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Re: The UR "peer to peer review" scam (California) (California)

Postby bakodoc on Mon Mar 23, 2015 5:03 pm

I guess I can only speak for myself. I provide my mobile number and invite to call any time they are ready... of course within deadline I'm given. My last review, I spoke with the requester twice because he didn't have the records the first time and had answered his assistant's call twice in order to make schedule for total of 4 phone calls for me. The case before that involved 5 calls. Only time I don't get to speak with the requester is when they seem to be avoiding the call. Either they are too busy when I call and never get back to me afterwards.

I can see why some of the reviewers are not very keen to talking with the requester though. If they had bad experiences, perhaps they are young and don't know how to handle it. I've had my own share of bad calls. Some requesters are downright rude. Some conversations begin with their questioning of my credentials from the getgo and they try to out do my credential as if that makes any difference. It's fight for them for some reason. I guess for some reviewers it's the same. Anyway, all I can assure you is that there's no conspiracy. I've worked with numerous UR companies and all of them were very professional and tried to prevent the kind of things you've posted. But I'm sure there are some bad companies as well like there are bad insurance companies. I don't deny the possibility as there are more companies I haven't worked with than I have. Just be courteous. There's really nothing to gain from being rude to the reviewer. They are treatment providers just like you. In my case, I try to see if there's a way to justify approval for fellow docs. There's no quota, there's no bias from the company and there's no pressure either. Some of the companies I work or worked with are major ones you'd know if I told you.
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