Preparing for Peer-to-Peer Reviews: A Practical Guide

The peer-to-peer review is often the most consequential conversation in the denial management process. It is a direct discussion between the treating physician and the payer's medical director (or reviewing physician) about whether a denied service is medically necessary. Done well, it can overturn a denial in a single phone call. Done poorly, it can cement the payer's position and weaken your case for subsequent appeal levels.

Despite these stakes, most physicians walk into peer-to-peer reviews with minimal preparation. They are busy clinicians, pulled away from patient care for a call they did not want in the first place. The payer's reviewer, by contrast, has the medical policy in front of them, has already reviewed the file, and has a structured framework for the conversation. This asymmetry of preparation is the single biggest reason peer-to-peer reviews fail to reverse denials.

Understanding the Format

A peer-to-peer review is typically a scheduled phone call between the treating physician (or a qualified designee, depending on the payer's rules) and the payer's medical director. The call usually lasts 10 to 20 minutes. Some payers allow scheduling at the physician's convenience; others offer narrow windows that may not align well with clinical schedules.

The format varies by payer, but the general structure is consistent: the payer's reviewer explains the basis for the denial, the treating physician presents the clinical case for the requested service, and a discussion follows. The reviewer may ask specific questions about clinical criteria, prior treatment history, or documentation details. In many cases, the reviewer will make a determination on the call or shortly after.

It is important to understand what this call is and what it is not. It is not an adversarial proceeding. It is not a negotiation. It is a clinical discussion between two physicians about whether the evidence supports the requested service under the payer's coverage criteria. Approaching it as a confrontation is counterproductive.

Pre-Call Preparation: The Non-Negotiables

Effective peer-to-peer preparation starts well before the call is scheduled. The following elements should be assembled and reviewed before any peer-to-peer conversation:

Know the Payer's Medical Policy

Before the call, obtain and read the payer's specific medical policy for the service in question. Most major payers publish their medical policies online, and they are updated regularly. The policy will list the clinical criteria the payer uses to determine medical necessity. Your job on the call is to demonstrate that the patient meets those criteria. If you do not know what the criteria are, you cannot address them.

Prepare a Clinical Summary

Create a concise clinical summary that includes:

• The patient's diagnosis and relevant comorbidities
• Current disease severity with objective measures (lab values, imaging findings, functional scores)
• Complete treatment history with dates, durations, doses, and outcomes for each prior therapy
• Specific reasons why the requested service is necessary at this point in the patient's care
• Relevant clinical guideline recommendations that support the service

This summary should fit on one page. The goal is to have every relevant fact at your fingertips during the call, organized in a logical sequence. Flipping through a 200-page chart during a phone call is not a substitute for preparation.

Anticipate the Objections

Read the denial letter carefully. The stated reason for denial tells you exactly what the payer's reviewer will focus on during the call. If the denial cited "insufficient documentation of medical necessity," be prepared to walk through the specific clinical data that supports necessity. If the denial cited "step therapy not completed," have the dates, durations, and outcomes of every prior therapy ready.

Common objections include:

• "The patient hasn't tried X therapy first." — Be ready to explain why that therapy is contraindicated, has been tried, or is clinically inappropriate for this patient.
• "The documentation doesn't show disease severity warranting this treatment." — Have objective severity measures ready with specific values and dates.
• "The requested service isn't supported by our medical policy for this diagnosis." — Know the policy and be prepared to cite the specific criteria the patient meets, or to argue that the policy's criteria are inconsistent with current published guidelines.
• "An alternative treatment would be equally effective." — Be prepared to explain the clinical basis for why the specific requested treatment is appropriate for this patient's circumstances.

Have Your Guidelines Ready

Cite published clinical guidelines by name, organization, and year during the call. "The ACR 2021 guidelines for rheumatoid arthritis recommend biologic initiation after failure of two conventional DMARDs" is more compelling than "guidelines support this approach." If the payer's medical policy conflicts with published guidelines, be prepared to discuss that discrepancy respectfully but directly.

During the Call: Strategy and Tone

The most effective peer-to-peer conversations follow a disciplined approach:

Listen first. Let the reviewer explain their understanding of the case and the basis for the denial. This tells you exactly what you need to address. Interrupting or launching into your case before understanding the objection wastes time and may cause you to address the wrong issue.

Be specific, not emotional. Statements like "my patient is suffering and needs this medication" are clinically uninformative. Statements like "my patient's DAS28 score has remained above 4.5 despite 14 weeks of methotrexate at maximum tolerated dose, meeting the ACR criteria for inadequate response" give the reviewer something to work with.

Address the criteria point by point. If the medical policy has four criteria for coverage, address each one explicitly. Do not assume the reviewer will connect the dots — make the case criterion by criterion.

Acknowledge what you do not have. If a specific piece of documentation is missing or a particular therapy was not tried for a valid reason, address it directly rather than hoping the reviewer does not notice. "The patient did not complete a trial of sulfasalazine because of a documented sulfa allergy, which I've noted in the chart" is far better than silence on the topic.

Stay collegial. The reviewer is a physician. They may disagree with you, but approaching the conversation as a professional clinical discussion between colleagues is more productive than adopting an adversarial stance. Hostility rarely changes clinical opinions; evidence does.

After the Call: Documentation and Follow-Up

Immediately after the peer-to-peer, document the conversation: who you spoke with, the date and time, what was discussed, and what the outcome or next steps were. If the reviewer agreed to reverse the denial, document that commitment. If additional documentation was requested, note exactly what was asked for and submit it promptly.

If the peer-to-peer does not result in a reversal, the documentation of the call becomes part of your record for subsequent appeal levels. A well-documented peer-to-peer conversation that identifies specific disagreements between the treating physician's position and the payer's position can strengthen a formal written appeal or external review request.

The Preparation Multiplier

The AMA's 2023 prior authorization survey found that physicians report spending an average of 12 hours per week on prior authorization activities. Much of that time is reactive and unstructured. Investing 15 to 20 minutes in focused preparation before a peer-to-peer review dramatically increases the probability of a favorable outcome — which means fewer subsequent appeal levels, less total time spent per case, and more revenue recovered.

The peer-to-peer is not an interruption in your denial management process. It is often the most efficient opportunity to resolve a denial. But efficiency requires preparation, and preparation requires a system. The practices that treat peer-to-peer reviews as structured clinical presentations — rather than impromptu phone calls — are the ones that consistently achieve higher reversal rates.