I Apparently Failed to Obtain Prior Authorization to Learn My "Peer Reviewer's" Identity.
I had to push back on prior authorization that isn't going through an appropriate peer review, with the help of Joe Feldman of Cover My Mental Health.
Welcome to The Frontier Psychiatrists!
What follows is a lightly edited account of two conversations: one between yout author and Joe Feldman, founder of Cover My Mental Health, and the inciting converstation, between yours truly and a peer reviewer at a major insurance company. The peer reviewer never identified herself by name. Company policy, she explained. We have honored that policy here, by keeping both her name and the companies identity completely secret. I'm sure no one in my leadership guess who the company is! It'll be like a fun game. You can even comment guessing who you think the company is, and I'm never gonna confirm or deny the answer.
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Part One: What the Rules About Insurance Authorizations Actually Say
Muir: Why does an insurance company have to actually cover anything at all? What are the rules they have to follow?
Feldman: Let’s start with the language of the insurance policy, which after all is a legal contract between the insurer and the individual. At the core of the contract, it says that we will pay for care that is medically necessary. They’ll put some limitations around that, some of which are completely reasonable. It has to be related to healthcare, and it has to be based on some diagnosis that a professional has made that says this is appropriate care. And that’s in the contract.
Muir: Well, I suppose they’re gonna need some sort of standards, Joe.
Feldman: Those standards are developed by practitioners and they’re reviewed by their peer practitioners. And those standards are published by organizations like the American Psychiatric Association, that describe the body of work that guides clinicians as to what care should be provided.
Muir: And what happens when the insurance company uses its own standards instead?
Feldman: The AMA made a statement in regard to some funny word play where one of these proprietary plans issued a statement that said, “No, no, no, our standards are based on the peer-developed standards.” And the AMA said: don’t be fooled. Based on is not the same as the actual article. The other related issue is that insurers may not disclose what those standards are and how they were applied. It’s holding their cards very closely and saying, “We’ve looked at our standards and this care is not medically necessary, but we’re not gonna tell you why.”
Part Two: The Call
I placed a peer-to-peer review call to [redacted subsidiary], a wholly owned subsidiary of [the same redacted company], seeking prior authorization for transcranial magnetic stimulation (TMS) for a patient with severe, primary obsessive-compulsive disorder. The following is drawn from that call experience. The call was an experience in much the same way that getting a nail in your tire is an experience. It forces you to slow down, reevaluate, and consider whether you need to learn how to change tires. The phone call and question happened before my conversation with Joe from Cover My Mental Mealth, so please understand it in that context…and now…the call:
Reviewer: Hi, I was calling for a peer-to-peer from [redacted subsidiary].
Muir: Yes. For a TMS request.
Reviewer: Yes. Hold on. Morning. Well, thank you for taking my call.
Muir: Of course. If you can just start by telling me your name, spelling it, and your training.
Reviewer: So I am… the company’s using initials at this point for security reasons.
She did not provide additional information that could be used to verify her identity or medical license.
Muir: The patient has severe and primary obsessive-compulsive disorder. This is an FDA labeled treatment for obsessive-compulsive disorder, and the treatment is being done with the BrainsWay H7 coil, which has multiple clinical trials that demonstrate its efficacy in this population, including large-scale trials that demonstrate its durability, which I was a co-author on. I’m happy to get into that data, but I understand it is not currently part of the coverage criteria for [redacted company], which is perplexing given the strength of the data supporting it.
Reviewer: Yeah. And that was the reason for the peer-to-peer. It’s not covered at this point.
Muir: As the peer-to-peer reviewer, have you ever treated a patient with transcranial magnetic stimulation?
Reviewer: So the “I” in the peer-to-peers… I’m reviewing based on the guidelines that the company uses.
Muir: I am aware of that.
We talk over each other a little bit here, and then I just find out if I can ask a question.
Reviewer: Ask me anything you like.
Muir: Have you ever treated a patient with transcranial magnetic stimulation?
Reviewer: I am familiar with TMS. I’m not treating with TMS at this point.
Muir: I’m asking you about your clinical experience. Have you ever treated a patient with transcranial magnetic stimulation?
Reviewer: So we’re talking about the policy guidelines.
Muir: No, we’re not. We’re talking about a patient. This is a peer-to-peer. You are a physician. I am a physician. Have you ever treated a patient with transcranial magnetic stimulation? It’s a yes or no question.
Reviewer: I answered the question. I am not treating patients with TMS at this point.
My much more savvy audience will notice, immediately, that's not actually an answer to the question. Nor was it previously answered, but moving on.
Muir: Do you manage patients with treatment-resistant obsessive-compulsive disorder?
Reviewer: I, I, I guess my question is, what, what are you, the peer-to-peer, I have to review based on what the policy guidelines allow for.
Muir: No, you don’t actually. No, you don’t. You have to review it based on generally accepted standards. Do you know what those are?
Reviewer: We use the guidelines that are based on evidence that we have available.
Muir: What evidence do you have available that says that you should not prescribe this treatment for OCD?
Reviewer: I’m using the [redacted subsidiary] clinical guidelines, which have a list of all of the references that have been reviewed.
Muir: Have you read the studies?
Reviewer: This is becoming a very difficult peer review…
Muir: Yes, it is. Please cite the research. Which evidence do you have?
Reviewer: I’ve already done that. You are able to review the guidelines, of course.
Muir: Please cite the evidence you’re using to support the denial of care for this patient.
Reviewer: I’m using the [redacted subsidiary] clinical guidelines, which have a list of all of the references that have been reviewed.
Muir: Look, I’ve read the same document you’ve read. Have you read the studies?
The call continued, tragically… nothing was resolved, and the patient got DBS brain surgery approved instead of this outpatient procedure. I'm not even kidding. I participated in that peer review also.
Part Three: What Should Have Happened
Muir: Joe, what is supposed to happen on one of these calls?
Feldman: The first order of business in a peer-to-peer review is a discussion about the patient’s care. It’s two peers talking to one another about this particular patient’s presentation, about treatment that has been tried before, and what leads the treating clinician to determine that X, Y, Z course of action is appropriate. Once that’s discussed you have at least a foundation to have a different conversation, which is: is this care that should be covered under this member’s insurance policy? So if you jump right to, “Wait a second, this care isn’t even covered,” you’re out of order.
Muir: And what about the qualifications of the reviewer?
Feldman: Both NCQA and URAC specify that in a peer-to-peer review, the competence of the clinician must be the same as the clinician who they’re speaking with. The essence of it is they have to have been in the same shoes as the treating clinician. It is reasonable to expect unambiguous confirmation of the training and the specific experience in a clinical scenario like the one that is being described. That is not negotiable.
Muir: And if they’re not qualified?
Feldman: There’s no shame in them saying, “You know what, I’m not the right person to have this conversation.” That’s perfectly legitimate. And their job should then morph to: I want to find someone who can help represent the interest of the insurance company, with someone who can say, “You know what, let’s have a conversation now about this treatment-resistant OCD and whether the care plan that you’ve identified is appropriate or not.” That’s a reasonable path forward.
Part Four: What You Can Do To Advocate For Your Patients
Muir: So let’s say this has happened to someone reading. What do they do?
Feldman: The first order of business, of course, is getting care to the patient on a timely basis. One of the observations that we make on Cover My Mental Health is to consider filing what’s called a formal insurer complaint. A complaint that goes directly to the insurance company that there is some issue with regard to the care delivery, where there’s a breakdown. Our investigation of this particular course of action suggests that you will get faster attention within the insurance company, because these formal complaints directly to an insurance company require reporting to their regulator and to their accreditation body. And that’s something that is a point of leverage.
Muir: does it go beyond the insurance company itself?
Feldman: There are three different organizations in government that could be appropriate for filing a formal complaint. A state attorney general is certainly one. Another would be the state insurance regulator. You can find a link to your state’s insurance regulator at the NAIC website. You can also file a complaint with the federal regulator responsible for this: the Employee Benefit Security Administration, EBSA. A complaint can be filed either online or by phone.
Muir: So if you really wanted to make sure the insurance company was on notice…
Feldman: You would file a complaint with the insurance company itself, so they’re aware. And with EBSA at the federal level. And with the state attorney general, in case it’s something they want to look into for their own reasons. And with the state-level insurance regulator, because insurance is regulated both on the federal and on the state level.
Muir: What’s the most important of those?
Feldman: I think the most important, and the most likely to have effect fastest, is a formal complaint to the insurance company. That would follow, for example, a medical necessity letter, or some documentation that a peer-to-peer review call was not being provided. Some evidence of that breakdown. Then having filed a formal complaint to the insurance company, that particular step can be included in a complaint that’s filed to a state regulator or a state attorney general’s office.
Muir: And a medical necessity letter, say more about that.
Feldman: A medical necessity letter from the clinician is, we think, one of the most important tools that a clinician can use to advocate for their patients. That can get the job done. It needn’t be a big battle and a campaign of many, many steps all taken in rapid-fire sequence. A medical necessity letter put on file may be sufficient. If that doesn’t get the job done, it could lead to a prompt to file a formal complaint. It could lead to a request for a peer-to-peer review. It could also lead to a formal appeal, which is in a typical insurance policy the formal dispute resolution approach that is provided.
Muir: And regulators, do our complaints actually reach them in a way that matters?
Feldman: I had a conversation with a state insurance regulator at a conference. He was from Mississippi. And I was talking to him about complaints coming in from clinicians, and I said, so how many of these complaints would you need to hear before you decided [that] we should probably investigate this? Would you have to have, what, twenty-five or fifty or something like that? And he said: if we had even a handful, we assume that there’s more out there that we will never hear about, and we’ll get after it. So assume that your one act of filing a complaint is going to make a difference.
Muir: The argument that I often hear is that this is all just too complicated, that they’re going to wait us out.
Feldman: The reason we buy health insurance is because we want to take care of ourselves and our families. And it’s just a reasonable expectation that that means the insurance company is gonna pay for the care that we need, based on the decisions of the clinicians who they have selected to be in their network to take care of us. That’s all we’re talking about. Clinicians and patients and families do not have to take no for an answer.
Cover My Mental Health offers free resources for patients, families, and clinicians at covermymentalhealth.org, including medical necessity letter templates, peer-to-peer preparation guides, and formal complaint templates. Resources are available in English and Spanish.
To file a federal complaint: dol.gov/agencies/ebsa
To find your state insurance regulator: naic.org
Prior articles on insurance coverage include…
Most of the newsletter also counts….
Ok finally came back to read this… I wonder if the person you spoke to is actually a practicing physician or NP? When I’ve done “peer to peers” it’s never an actual clinician. It’s someone who “facilitates” the process and makes the recommendation that gets a final review by someone I never speak to.
Without even reading this article my stress level zoomed to a 10! I’ll try to read when I’m not mad at these insurance companies - Jamie