I currently work as an authorization specialist at a cancer hospital. My team
works on obtaining authorizations for patients with scheduled radiology
services. When insurance companies deny a scan, they typically provide an
option for the ordering provider to conduct a peer 2 peer review. A peer 2
peer review gives an ordering provider an opportunity to present more
information describing why the scan in question is medically necessary. My
hospital designates a separate team of advanced practice providers (APP) to
make these calls and conduct peer 2 peers.
My team communicates with $the APP team to dispense relevant information
for each patient and the APP returns to my team to report the outcome of the
peer 2 peer. $When APP's call for a peer 2 peer , they speak with a Nurse or
Doctor employed by the insurance company. My hospital uses APP's that see
patients in a clinical setting for half of their time and then for the other half
they work on peer 2 peers.
Most APP's in clinics use technology to screen and care for patients
physically. They also use electronic medical record systems to write consult
notes and record progress for each patient.
APP's employed by an insurance company typically worked with patients
physically, but currently use their medical knowledge to help decipher which
course of treatments are medically necessary for a patient's plan of care from
the insurance company's perspective. They typically use technology to
evaluate information presented by a provider's APP and record the final
determination after a peer 2 peer has been completed.
This varying spectrum of roles and functions affects the management of
information by requiring different skill sets from each Advanced practice
provider. APPs employed by an insurance company require less emphasis on
bedside manner, and more focus on practical knowledge. An APP working in
a clinical setting must have an excellent bedside manner and must be
proficient with all medical technology.$
