Audio Coursesby JellypodLesson 09 of 17
Overview
Vicky Muller: Welcome back to Starting Strong, everyone. I’m Vicky Muller, and I’m here with Beth Blimmer and Mark Krause. Today, we’re diving into something that, honestly, every hospitalist will face sooner or later—peer-to-peer calls, or P2Ps. These are those sometimes nerve-wracking phone calls between us and the insurance company’s medical director, usually after a denial. And, let’s be real, they can make or break whether our patients get the care they need—or whether we get paid for the work we’ve already done.
Beth Blimmer: Yeah, and I think a lot of folks, especially when they’re new, don’t realize just how central these calls are to hospital medicine now. It’s not just about arguing over a discharge plan. P2Ps can pop up for all sorts of reasons—like, maybe the insurance reviewer doesn’t think the patient really needed to be inpatient, or they’re questioning a diagnosis, or even the plan for post-acute care. I remember my first one, I was so nervous I could barely hold the phone steady.
Mark Krause: Oh, totally. And, you know, it’s funny—people always assume it’s the attending who kicks off the process, but it’s almost always the nurse case manager who lets you know, “Hey, you’ve got a P2P coming up.” They’re the unsung heroes in this, honestly. And the most common reason for denial? Nine times out of ten, it’s missing or unclear documentation. Not some big billing error, not the length of stay—just, like, not enough detail in the chart.
Vicky Muller: That’s so true. I had a case not long ago—older patient, pretty complex pneumonia. The chart was, well, let’s just say it was a little thin on details. I got the call from our NCM, and I knew I had to do a P2P. The insurance reviewer was a family med doc, not even close to pulmonary. I had to walk them through why this patient really needed inpatient care, and I’ll admit, I was sweating it. But I went back, reviewed the chart, made sure I could explain the severity, and just focused on the clinical story. It worked out, but it was a reminder—these calls are about telling the right story, not just rattling off labs.
Beth Blimmer: And sometimes, the reviewer’s got access to the EMR, so you can’t fudge anything. You’ve gotta be specific, and you’ve gotta be accurate. I always tell new folks: don’t take it personally if you get a denial. It’s just part of the job now.
Mark Krause: Yeah, and the denials aren’t always about medical necessity, either. Sometimes it’s clinical validation—like, they’ll say, “Nope, we don’t buy that sepsis diagnosis,” and try to downgrade the whole thing. Or they’ll push back on post-acute plans, like SNF or rehab. It’s a lot to keep track of, but once you get the hang of it, it’s just another part of the day.
Beth Blimmer: So, let’s talk about how to actually win these calls—or at least give yourself the best shot. First thing, you’ve gotta prepare. Like, really know your patient. I mean, I’ve definitely tried to wing it before, and it never goes well. You want to review the chart, know what makes this case inpatient-appropriate, and be ready to explain it in plain language. And, oh, keep your phone on you. Missing the call is the worst.
Mark Krause: Yeah, and if you do miss it, just call back right away. Don’t wait. I always tell people, “Don’t let it sit—just get it done.” And, you know, when you’re on the call, let the reviewer talk first. Ask them why the case was denied. Sometimes you’ll find out it’s just a missing note or a lab that didn’t get scanned in. Then you can fill in the gaps instead of going point by point defending every order.
Vicky Muller: Exactly. And keep it professional, even if you’re frustrated. I know it’s tempting to get defensive, but it never helps. Just focus on the clinical narrative—why this patient needed what you ordered, what risks there were if they’d been managed elsewhere. And if you lose, don’t chart the outcome in the EMR. Just let your NCM know. They’re the ones who track these things and help with appeals if needed.
Beth Blimmer: And you don’t usually need to tell the patient about the denial, unless it’s going to affect their discharge plan. I always check with case management first. But, yeah, the main thing is to stay positive and use every denial as a learning opportunity. I started keeping a little list of common denial reasons, and it’s helped me spot patterns in my own documentation.
Mark Krause: That’s a great point. I mean, if you keep seeing denials for the same diagnosis, like sepsis or cellulitis, it’s probably time to update how you’re documenting those cases. And, honestly, sometimes it’s just about painting a clearer clinical picture. Like, could this patient have been safely managed at home? If not, why not? That’s what the reviewer wants to hear.
Vicky Muller: And don’t forget, your NCM is your partner in this. They’re tracking outcomes, helping with appeals, and they know the ins and outs of the process. If you’re not sure what to do, just ask them. It’s a team effort.
Mark Krause: Alright, let’s put this into practice. Say you’ve got a 78-year-old admitted with pneumonia, but the chart’s a little light on details. You get a P2P scheduled. What do you do? Well, you go back, review the chart, and make sure you can clearly explain why inpatient care was needed—like, was there hypoxia, was the patient unstable, did they need IV antibiotics? That prep can make all the difference.
Beth Blimmer: Yeah, and I had a run of cellulitis denials last year. Three in a row, actually. It was kind of a wake-up call. I sat down with our NCM, we reviewed the charts, and realized we weren’t documenting the failed outpatient treatments or the risk factors that made inpatient care necessary. So, we changed our approach—started being more explicit in the notes, and the denials dropped off. It’s not fun to lose, but it’s a chance to get better.
Vicky Muller: And with sepsis, it’s the same thing. If the reviewer questions the need for IV fluids or monitoring, you’ve got to be ready to talk about instability, abnormal labs, and why outpatient care just wasn’t safe. It’s about using the clinical context to reinforce your case. And, honestly, every time you go through this, you get a little sharper. You start to see what the reviewers are looking for, and you adjust your documentation and your approach.
Mark Krause: It’s like, every denial is a free lesson—well, maybe not free, but you know what I mean. And it’s not just about getting paid, it’s about making sure our patients get the right care. Plus, it keeps us on our toes. I always say, if you’re not learning from your denials, you’re missing out on some of the best feedback you can get.
Beth Blimmer: Totally. And, you know, it’s not just about us, either. When we get better at this, it helps the whole team—case managers, nurses, even the next patient who comes in with a similar problem. So, don’t be afraid to ask for help, review your cases, and keep improving.
Vicky Muller: Alright, I think that’s a good place to wrap up. Thanks for joining us on Starting Strong. Remember, every P2P is a chance to advocate for your patient and sharpen your skills. We’ll be back with more tips and stories next time. Mark, Beth, always a pleasure.
Mark Krause: Thanks, Vicky. This was great. See you both next time.
Beth Blimmer: Thanks, everyone! Take care and keep learning out there.
