The Perils of Physician Communication Gaps in Utilization Review

| | Physician Peer Review

physician communication gaps
Sometimes during the utilization review (UR) process, a reviewing physician needs to contact the requesting physician for more information on a case.

When the reviewing and the requesting physicians are unable to communicate with each another, the reviewing physician has to make a decision based on information available. The information may be incomplete, resulting in denials that could have been avoided.

3 Common Physician Communication Gaps in UR

For UR to be effective, doctors and UR companies need to address these key communication issues:

1. Doctors Unable to Connect: One of the biggest problems in UR occurs when a reviewing physician attempts to contact a requesting physician, but they do not connect. The requesting physician may be away from the office, unavailable for conversation, or simply not return the call. The reviewer, then, cannot obtain the clarification or additional information needed to thoroughly review the case.

2. Incomplete Files: Before a UR doctor receives a case, it passes through a number of hands: A requesting physician sends it to the insurance company, which forwards it to a UR nurse, who forwards it to a UR physician (when necessary). Along the way, information may get lost. For example, the insurance company may not include an MRI report the requesting physician mentioned in his notes. Without access to this report, and if the reviewing physician cannot reach the requesting physician, the reviewing physician does not have the information needed to make the best possible treatment decision for the injured employee.

3. Unprepared Doctors: If a reviewing physician does not read a patient’s records in advance, they will not know the particular nuances and guidelines surrounding a request. The reviewer won’t know what questions to ask of the requesting physician, nor what information, if any, is missing. The reviewer will only be able to ask general questions about the case. Ultimately, not being prepared may lead to sub-par decisions.

How to Improve Physician Communication in UR

Fortunately, the causes of disconnection and miscommunication between physicians are easily remedied. Physicians need to develop these habits:

Educate Requesting Physicians: Often, requesting physicians view calls from reviewing physicians as adversarial or punitive; they may become defensive and resist working with reviewers. However, reviewing physicians call because they want more information – information that will help them approve requests. Requesting physicians need to understand that when reviewing physicians call, they’re calling because they want to help.

Leave Detailed Messages: If the requesting physician’s office does not answer the call, the reviewer should leave a message that specifically details which records he needs. This way, even if the requesting physician doesn’t have a chance to call back, someone else in the office can hear the message and forward missing information.

Compare Notes: At the outset of the UR process, the reviewing physician and the requesting physician should make sure they are both looking at the same records, files and notes. This allows reviewing physicians to catch and obtain missing information early in the treatment process.

The reason peer-to-peer phone calls occur in UR is that something in the request doesn’t fall within applicable guidelines. The purpose of the calls is to get clarification and needed information.

Ultimately, both doctors are trying to help the same patient. Therefore, clear, comprehensive communication between requesters and reviewers is absolutely necessary to ensure the best possible outcomes for patients.

Zenia Cortes, MD, Orthopedic Surgeon

Dr. Zenia Cortes brings her combined expertise in sports and orthopaedic medicine to UniMed Direct, along with insights from her experience in peer and utilization review.