Prior to the onsite physician advisor coming to our facility,
we struggled with utilization review process in regard to peer-to-peer denials.
The doctors didn’t want to do peer-to-peers because they felt like they were being treated mean.
The intimidation factor of the insurance companies kept them from doing the peer-to-peers
because they just wouldn't do them.
They didn't know how to talk to the insurance companies or what was being expected of them.
We relied on nurse case managers to pretty much give them the information that they needed
to do an appeal, it wasn't enough information and we were losing a good percentage of our appeals.
She's in the building five days a week, Monday through Friday, and then we also have the
remote support for evenings, weekends, and holidays, so that our cases are reviewed rapidly,
and the turnaround time is excellent.
She can actually get into the patient's record and from looking at their documentation
she knows what that physician is thinking and feeling,
it helps her to fight on the peer-to-peer or the back-end side of it too.
Our physician advisor has embraced our hospital, she understands where we're coming from, the
clientele we take care of, also the challenges we have with some of our doctors.
Our response rate to her requests has increased to 94%.
That shows to me that they respect her decisions.
The main positive result that I can speak to, prior to our onsite physician advisor,
we were only winning about 33% of our appeals.
Since we've brought on the onsite physician advisor, we are up to 54%, which I think is
an astronomical change and the value on return on investment is great.
Optum has been great at providing service to our facility and customizing it to us.
If someone came to me and asked me, should they go with Optum to help with their peer-to-peers,
their denials appeals, or just making determinations, I would say yes, they should go with them.
They have the legal and the medical background
to make that decision and be there to stand behind you.