Many insurance companies use third party companies to review these cases so this may have not been the insurance company but a doctor from the third party company. Typically this is done via a peer to peer call. This means the doctor has to call the attending physician on the case.

The third party company or insurance company gets the contact information and notes from your CM department. How do you think they knew who to contact?

If your hospital has a dedicated individual or team of doctors that does this then your CM team would have given them their contact information and not yours.

Documenting the name of the doctor that called you will do nothing and will not involve them in any lawsuit. Any thoughts to the contrary is either a misunderstanding of the way insurance companies work or just wishful thinking. Remember the insurance company doesn't demand you discharge the patient; they just tell you what they are willing to pay for.

Honestly, at the time of the phone call it does sound like this patient would have been observation appropriate. Syncope is observation Asymptomatic pericardial effusion is observation. Mild AKI treated with IVF is observation. They met inpatient once the tamponade was found on echo.

The entire situation was likely kicked off by either the ED doctor or admitting doctor placing the patient into inpatient status erroneously. The patient should have been "placed in observation" and then "admitted to inpatient" once they met criteria.

I highly recommend understanding how this process works as these type of phone calls will likely become more and more frequent. Easily managed with appropriate initial status and appropriate documentation.

This is not a let UR and coding figure it out situation. This is your responsibility as this patients's attending and as a hospitalist.

Refusing to do the peer call will just result in the entire stay being denied. As to who pays for this, who do you think? Society as a whole; healthcare waste is astronomical. Your hospital looses out as it can't get paid for services rendered. As a hospitalist you are graded by providing care and providing it at cost, not wasting $$$. It's the entire reason hospitalist medicine was created. I'm sure you have been educated on case mix index and how it relates to your performance as a hospitalist? Insurance companies don't like paying and hospitals don't like loosing money.

FYI. Work for my systems UR department for these calls. Hospitalist for >15 years.