When to Use Peer-to-Peer Reviews: A Practical Guide for Getting Denials Overturned

When a payer denies a medically necessary service, a peer-to-peer review (P2P) can be the quickest route to a reversal. But here's the thing: most practices either don't use it enough, use it at the wrong time, or don't prepare their physicians adequately when they do. Getting this right can mean more denials resolved in a single conversation instead of a trip through several written appeal levels. Let's break down exactly when and how to leverage P2Ps effectively.

What a Peer-to-Peer Review Actually Is (and Isn't)

A peer-to-peer review is a direct conversation between your treating physician and the insurance company's medical reviewer — typically another physician or clinical peer. The goal is to discuss the clinical rationale behind a denied service and, ideally, get that denial overturned before you're stuck grinding through multiple levels of formal appeals.

What it isn't: a guaranteed win, a casual phone call, or a billing conversation. Billing staff can flag the case, request the call and help prepare the summary, but the call itself is a clinical conversation that needs an engaged, prepared physician.

P2Ps are most commonly available after an initial denial — particularly for prior authorization denials or concurrent review denials during inpatient stays. The window to request one is often narrow, sometimes just 24 to 72 hours after the denial notice. That's why your team needs a process in place to flag these quickly rather than letting denials sit in a queue.

The Right Times to Request a Peer-to-Peer

Not every denial warrants a P2P. Knowing when to deploy this resource — and when to skip straight to a written appeal — saves your physicians' time and keeps the process strategic.

Go the P2P route when:

• The denial is based on medical necessity and the clinical picture is complex or nuanced. Insurers often apply blunt criteria (like InterQual or MCG guidelines) that don't capture the full story. A physician can explain what the chart can't always convey.
• You're dealing with an inpatient or observation status dispute. These situations move fast and the financial stakes are high. Getting a real-time conversation with the payer's reviewer can stop the clock before a patient is administratively discharged.
• The denial feels like the reviewer missed something obvious. Maybe they didn't see a recent lab result, a failed conservative treatment, or a comorbidity that changes the picture entirely. A physician can connect those dots in a conversation more efficiently than a written appeal.
• You're dealing with a high-dollar claim. A short call that resolves a costly denial is worth far more than the physician time it takes.

Consider skipping the P2P when:

• The denial is for a coding error or billing issue — that's not a clinical conversation, it's a corrected claim.
• The payer's denial is based on a contractual exclusion. No amount of clinical justification changes a benefit limit.
• You've already gone through a P2P and lost. At that point, move to formal written appeals and consider escalating to an external review if warranted.

How to Prepare Your Physician for Success

This is where most practices leave money on the table. The physician gets handed a phone number, maybe a fax number, and a vague "the insurance company denied this, can you call them?" That's not a strategy — that's hope.

Here's what actually works:

Before the call:

• Pull the denial letter and identify the exact reason code. Know which clinical criteria the payer cited — whether it's a specific InterQual level of care criteria or a local coverage determination.
• Prepare a concise clinical summary. The physician shouldn't have to dig through the chart during the call. Have someone on your team prep a one-page summary: diagnosis, relevant history, failed prior treatments, current status, and why this level of care or service is necessary.
• Know the patient's plan details. Some payers have specific peer review policies that differ from their standard coverage rules.

During the call:

• The physician should lead with the clinical narrative, not the billing language. "This patient presented with X, had failed Y and Z treatments, and required this service because..." is far more persuasive than reading CPT codes.
• Ask the reviewer questions too. What specific criteria wasn't met? Is there additional documentation that would change the determination? This creates an opening for negotiation.

After the call:

• Document everything. Date, time, name of the reviewer, what was discussed, and the outcome. If you get a verbal approval, follow up in writing immediately and request confirmation.

Tracking Outcomes and Improving Over Time

Here's something a lot of practices overlook: P2P reviews are a goldmine of data if you track them properly. Over time, you'll start seeing patterns — certain payers who regularly deny specific procedures, physicians whose documentation makes P2Ps easier to win, or service lines where your clinical justification language needs strengthening.

Build a simple tracking log that captures:

• Payer name
• CPT/service denied
• Denial reason
• Whether a P2P was requested (and outcome)
• Time from denial to P2P request
• Was the denial ultimately overturned?

Even a basic spreadsheet works. After six months, you'll have actionable intelligence that helps you get ahead of denials rather than constantly reacting to them.

This kind of data also shows when a particular payer has a pattern of questionable denials, which is useful evidence if you ever need to escalate to your state insurance department or raise it in contract negotiations.

Where P2Ps Fit in Your Broader Appeals Strategy

A P2P should be one tool among several, not your entire plan. Think of your appeals workflow as a layered approach: first-level appeals, peer-to-peer reviews, second-level appeals, and external independent reviews are each suited for different situations.

If your team is overwhelmed by denial volume, a drafting tool can take some of the load. EZAppeal, for example, drafts appeal letters in a few minutes, citing the payer's policy when one is on file, for your team to review and send, so physician time can be reserved for the P2P conversations that actually need their clinical voice.

The goal is to match the right response to the right denial. P2Ps are time-intensive for physicians. Use them where they'll have the most impact.

Putting This Into Practice

Start this week by auditing your last 30 denials. How many were eligible for a P2P review? How many did you actually request? If there's a gap — and there almost certainly is — that's your opportunity.

Build a simple protocol: denial comes in, billing flags P2P-eligible cases within 24 hours, clinical liaison preps the summary, physician is notified with a specific time window to make the call. It doesn't have to be complicated. It just has to be consistent.

Peer-to-peer reviews won't solve every denial problem, and they're not magic. But when used at the right time, with a prepared physician and a clear clinical narrative, they're one of the most effective levers you have. Your patients got the care they needed — now make sure your practice gets paid for it.