It was the patient’s inability to swallow medicine that helped persuade a medical director at a Medicare Advantage (MA) plan to reverse the denial of an inpatient admission. During a peer-to-peer call with the hospital’s physician advisor, the medical director approved the admission because the patient required IV fluids and tube feeds.

“This was day three and they still needed infusion of IV fluids,” said Steven Grant, M.D., network chief physician advisor for the University of Vermont (UVM) Health Network in Burlington who did the peer-to-peer call with the MA plan’s medical director. “The IV meds end up being a salient thing because that’s not something you generally do outside the hospital,” he said.

Even though hospitals win some and lose some, having a physician from the hospital respectfully try to persuade an MA medical director to cover the inpatient admission seems to be the better way to go compared to appealing denials after the fact, Grant said.

“Peer to peer is the best chance of success,” he said. “We shouldn’t ever miss a peer-to-peer opportunity.” There were plenty of times in the past that UVM Health Network didn’t engage in peer-to-peer calls to try to overturn denials of medically necessary inpatient admissions under the two-midnight rule when patients crossed two midnights, but that’s not the case anymore. “We don’t fight every case, but we try to fight the ones we think are legitimate,” Grant said.

He doesn’t think of peer-to-peer calls with MA plan medical directors as a technique per se. “I see them as my colleagues. They just have different employers,” Grant explained. “I try to have good calls. I try to keep it professional and friendly.” Although “you can’t get everybody to agree with you, you can be respectful.”