The Peer-to-Peer Consultation: you are not my peer.
I am a GYN Oncologist. I work in the high stakes realm of cancer care. I strategize complex treatment plans involving surgery, radiation, chemotherapy and the newer biological agents to treat the myriad of disease that we call collectively “cancer”. Cure, or at least control, requires urgent and timely administration of these modalities along with various imaging or blood work to assure that the treatment prescribed is effective. I love my job as each day; I am privy to observing the resiliency and grace from those of whom I am fortunate enough to care. Oncology remains a profoundly rewarding profession.
But the care I provide comes at a cost. In addition to the human toll the prescribed therapy takes out of the patient and her family, there is, of course, a financial burden. Chemotherapy can cost tens of thousands of dollars per month and imaging, such as a PET scan can cost upwards of five thousand dollars per test. In efforts to control cost, insurance companies have implemented numerous policies to reduce the number of what they consider to be “nonindicated” tests. My favorite (yes, I’m being facetious) is the peer-to-peer consultation.
Most patients are unaware of this, but your physician is likely your biggest advocate when it comes to getting your care covered. At least weekly, and occasionally daily, insurance companies deny payment for some cancer treatment that I prescribe. In my career, I cannot think of a single aspect of the cancer care continuum that HASN’T been denied: surgery, chemotherapy (I once had to cancel a patient’s scheduled chemotherapy which was both effective and well tolerated, 3 months into treatment due to an insurance company refusing to pay for more treatment. They also wanted their money back for the three previous treatments. In the end, they covered the service), consultations to other medical professionals such as Genetics and physical therapy, medications to cover chemo induced nausea, imaging such as CT scans and PET scans, oh and this is a good one – back billing of a patient’s estate for the three grand after she died, for a test to see if the chemo would be effective. It was not.). As expected, as the cost is so high, denial of payment equates to a denial of service. After a series of denials and re-requests (which can delay treatment for weeks), the final step in the process of getting the service paid for is the “peer to peer consultation”.
In the peer to peer consultation, Peer 1 (that sounds too much like a store so let’s say) Peer A, the insurance company physician, almost never trained in oncology and Peer B (i.e. me) discuss, by phone, the medical scenario of the patient and why she is in need of the previously denied, prescribed service. It may go something like this (in fact this one happened last month):
Peer A – Insurance Doc: (matter of factly) “I’ve reviewed your patient’s case and see that you would like the denial of services for her PET scan overturned. Is that right?”
Peer B – me: (pleasant, business casual) “Yes that’s right. Let me tell you her story.”
Peer A – Insurance Doc: “Sure.”
Peer B – me: “This patient has a history of recurrent metastatic cervical cancer. She is presently in remission. She was initially treated for stage Ib squamous cell carcinoma with radical surgery. She recurred in the pelvic a year later and was treated with concurrent chemoradiation therapy and was in remission for another year. A PET scan then found two lung lesions. These were NOT seen on a CT scan prior to that. These lung lesions were removed surgically and she’s been in remission for the past year. I would like to do a PET scan to make sure no small recurrence is present as she is at such high risk having recurred twice already.”
Peer A – Insurance Doc: “You said she’s in remission, so there’s no need for a PET scan.”
Peer B – me: “Her CT from three months ago was normal, but as I mentioned, in the past her CT was falsely negative and her recurrence was only identified on a PET scan, giving us time to effectively treat her and get her back into remission.”
Peer A – Insurance Doc: “Let me check the policy… Wait, do you know if PET scans are approved for cervical cancer.”
Peer B – me (now annoyed): “Yes, PET scans are approved for cervical cancer and may have saved the woman’s life. What is your specialty training?”
Peer A – Insurance Doc (now annoyed): “I’m board certified in Family Medicine. Oh, here it is. The policy states that if the CT is positive, then the PET will be covered. So I’ll approve a CT scan.”
Peer B – me (trying to maintain composure): “I’m board certified in GYN Oncology. And in oncology school we review the data to determine the most effective treatment and follow up. Clearly, CT scanning is suboptimal in this patient. She really needs a PET scan.”
In the end, the PET scan was denied. I couldn’t convince Insurance Doc by scientific reasoning or rational argument, that his circular logic was faulty and the patient may pay with her life for Insurance Doc’s inability to look beyond policy. Her CT was approved, performed and was normal for whatever solace that gives us.
I have been doing peer-to-peer consultations for at least five years now. In the past, a discussion of the clinical scenario and available patient data would not infrequently overturn the denial. Not so much now. My approach of educating the insurance physician reviewer to present oncology standard hasn’t changed, but is now rarely successful. My tone may have degenerated a bit over time as the frustration of getting care covered has increased. And I wonder aloud, didn’t we have the same degree? Didn’t we have the same training? Didn’t we have the same idealistic view of changing the world one patient at a time? Didn’t we take the same oath that began primum non nocere – first do no harm? So when did our paths diverge? Our values and goals to provide our patients with the utmost in cutting edge and compassionate care, once the same, have strayed. And although it may have been so in the past, presently I must conclude: Insurance Doc, you are not my peer.
This article was recently published on KevinMD.com.