Peer-to-peer review: what it is and how to prepare

2 min read

When a request is heading for denial on medical necessity, most plans offer a peer-to-peer: a discussion between the ordering physician and the plan's physician reviewer. It is usually short, frequently offered in a narrow window, and it is the least expensive point at which an adverse decision can be reversed.

#What it is for

The reviewer has applied criteria to a documented case and found it short. The peer-to-peer exists to let the treating physician supply what the documentation did not carry: clinical context, reasoning, or the specific facts of why the standard pathway does not fit this patient.

It is not an appeal and it is not an argument about policy. It is a clinical conversation with somebody who is applying a written standard and who generally has discretion to certify when the clinical case is made.

#Preparing

Know which criterion is unmet: Ask before the call what specifically was not met. Going in without this means spending the call discovering what the disagreement is, and the call is short.
Have the record open: Dates of conservative management, results, prior attempts. The reviewer will ask for specifics and "I believe we tried that" does not move a determination.
Decide which case you are making: Either the patient does meet the criteria and the documentation failed to show it, or the patient does not meet them and there is a clinical reason the standard does not apply. These are different conversations and mixing them weakens both.
Know the alternative: If the reviewer proposes a less intensive option, having a specific clinical answer as to why it is inappropriate for this patient is far stronger than a general preference.

The window is real

Peer-to-peer is frequently offered for a limited period, sometimes only before the formal denial is issued. Missing it does not remove appeal rights but it does remove the fastest and cheapest route. When a plan offers one, treat scheduling it as urgent even if the procedure is not.

#Afterwards

Record the outcome, the reviewer's name, the date and any reference number, whichever way it went. If the determination was reversed you need the record. If it was upheld, the fact that a peer-to-peer occurred and what was discussed is material to the appeal that follows.

Practices that track peer-to-peer outcomes by payer and by procedure learn something useful quite quickly: which denials are worth the physician's time and which are reliably upheld. That is a scheduling decision worth making with data rather than instinct.