Physicians who have not participated in a peer-to-peer medical insurance review are the exception rather than the rule. The AMA found that 61% have had to “at least sometimes” engage in peer-to-peer reviews to obtain approval from a patient’s healthcare insurer for what they deemed to be medically necessary treatment.
Below, we’ll explore exactly what a peer-to-peer review is, whether it can affect a physician’s malpractice insurance coverage, advice for discussing treatment with a reviewer, and more.
A peer-to-peer review is a phone discussion between a healthcare provider and a medical professional representing a patient’s health insurer regarding the patient’s treatment. It typically occurs after the insurer has denied prior authorization (PA) of or a claim covering a procedure, medical device, hospitalization, or medication that the provider recommended.
Essentially, it is a phone call in which the patient’s provider works to convince the insurer’s physician of the medical necessity of their recommendations.
Also known as P2Ps, the value of payer-to-provider peer-to-peer reviews is highly debated among healthcare professionals. Advocates cite them as a way of managing healthcare costs by preventing providers from recommending costly services that have little value to the patient.
Proponents also note that because peer-to-peer reviews take place over the phone, they enable physicians to go into far greater detail to justify their recommendations than filling out appeals paperwork would, thereby improving the likelihood of getting denials overturned.
One analysis shows that while written appeals have a 40%–60% overturn rate, well-prepared physicians participating in P2P calls have 55%–75% of denials being overturned. Phone calls also allow for faster resolutions than written appeals typically do.
Although some say P2Ps help speed up the process of getting denials overturned, 94% of physicians surveyed by the AMA said peer-to-peer reviews and the prior authorization process in general have led to delays in patients’ receiving the care they need. In addition, 56% of physicians report more peer-to-peer reviews since 2019, making the review process even more burdensome.
Reviews eat into physicians’ time as well. While the actual P2P phone conversation often lasts only five to ten minutes, the surrounding process is still time consuming, including preparation and the effort of actually dealing with the insurer’s representative, which often means waiting on hold or having to disrupt other activities when the insurer calls back. That can delay a clinical decision and timely determination.
Physicians also are skeptical regarding the qualifications of the insurer “peers.” Just 16% believe that the clinicians representing the insurance company often or always have the appropriate qualifications; for instance, not all states require the reviewers to be specialists in the same specialty as the patients’ physicians. Reviewers need the right knowledge and expertise, and roughly half of U.S. states have legislation regulating prior authorization reviews. Some laws also require a reviewer to be licensed and appropriately matched to the case; for example, New Jersey passed a 2023 law requiring qualified reviewers.
These are among the reasons only 18% of physicians surveyed said they always appeal a PA denial. Nearly half (48%) said a lack of resources has kept them from participating in peer-to-peer reviews and other appeals.
Yes, a peer-to-peer review is entirely different from peer-to-peer medical cost sharing. The latter is an agreement among a group of consumers to pool monthly contributions to help pay for large healthcare expenses of fellow group members. It’s generally a substitute for health insurance, with its own restrictions and caveats: Most don’t cover preexisting conditions, for instance, and they can refuse to accept members based on lifestyle choices such as smoking and drinking.
A peer-to-peer medical insurance review also differs from, and can be confused with, an internal clinical peer review. The latter is a quality assurance check of hospital, clinic, or practice staff conducted by their colleagues; it might include retrospective chart reviews and pre-implementation treatment reviews.
By contrast, traditional peer review is a more formal quality-control process used mainly in academic publishing, often with a participant hierarchy that includes independent senior experts. More formal models usually take longer because of structured procedures, and medical peer review can also appear in settings beyond insurance and medicine, such as education or software development.
Plaintiffs can use payer-to-provider peer-to-peer reviews to strengthen their medical malpractice claims. Defending attorneys may use them to show that the physicians advocated strongly enough for the patient to mitigate their liability. Because attorneys can subpoena recordings of P2P reviews and notes regarding PA requests, including the insurer’s review process and resulting coverage determination, maintaining accurate, consistent documentation is crucial.
To prove any medical malpractice claim, the plaintiff needs to establish four key elements:
Say an insurer refuses to pay for a certain cancer treatment prescribed by a physician. If the physician does not advocate in the peer-to-peer review as forcefully as other providers have in the past, resulting in the denial being upheld and delays in prior authorization approval affecting the patient’s care, the physician could be liable for breach of duty or negligence.
That said, there are no readily available reports of physicians being legally found guilty of medical negligence or malpractice solely for failing to fight strongly enough to overturn an insurer’s denial of treatment. However, if other factors such as a failure to diagnose or an inadequate discharge plan are also cited in the suit, the physician’s acquiescence in the peer-to-peer review could in the eyes of a judge or jury substantiate the negligence or malpractice charge.
Let’s return to the example of an insurer refusing to approve a physician’s prescribed cancer treatment. This time the physician makes a strong case in the P2P review and in follow-up appeals but is still denied. Despite opting for alternative treatment, the patient suffers long-term ramifications and includes the practitioner in a malpractice suit.
Documentation proving that the physician did at least as much as, if not more than, the average provider would do to secure prior authorization approval for the recommended treatment could well absolve them from liability if the request was never approved.
To “win” a peer-to-peer medical insurance review, a physician should review the reasons treatment was denied, have all relevant clinical records at hand, and maintain a respectful, professional attitude. While this won’t guarantee the overturning of a denial, it has been proven to increase the likelihood of success.
Why an insurer denied the treatment determines how a physician should appeal. If a clerical error or missing documentation triggered the denial, the most effective response is to correct the mistake and resubmit the request as soon as possible.
When the payer denies care as medically unnecessary, however, the ordering physician can request a peer-to-peer review to explain why the treatment or drug is medically necessary for the patient’s condition. The same is true of a “fail first,” or step therapy, denial. This requires the physician to try insurer-preferred alternatives first; in this case, you could request a P2P review to prove they’re ineffective or contraindicated for the patient and that the recommended treatment is the only suitable alternative.
In some instances, physicians can also request a peer-to-peer review if the treatment was denied because it is excluded from the coverage terms or the provider is out of network. Payer denials may also involve medical orders or inpatient status. In these instances, you would use the review to show that no covered alternative treatment or adequate in-network provider exists.
Once you’ve determined a P2P review is warranted, schedule one as soon as possible and within the insurer’s or health plans deadline for requesting the review. Each insurer has its own timeline: some require contacting the payer within 72 hours of being issued a denial, others allow two weeks.
When calling the provider services number to schedule the review, the call is typically set between the ordering physician and the insurance company's medical director or another physician reviewer. It is likely you will need to supply the following pieces of information:
Along with clinical notes, charts, lab results, and imaging studies, documentation should include records of prior treatments that proved ineffective or are contraindicated. You should also gather relevant evidence-based specialty guidelines and current peer-reviewed literature that support your treatment plan, and make sure that supporting literature is up to date.
This is especially important when the treatment was denied because the insurer considered it experimental or investigational. If the treatment was denied due to being excluded from coverage or out of network, include documentation of efforts to find adequate alternatives.
Write a concise summary the ordering physician discusses with the reviewer, explaining the diagnosis, any failed prior treatments, and the clinical rationale for your prescribed treatment, with the goal of clarifying the clinical decision and why the requested treatment is appropriate. You should be able to state this summary in just a few minutes.
It’s easy to conduct yourself in a combative way during a peer-to-peer review. Don’t. Instead open with a congenial greeting and assume the best of intentions from the insurer’s representative. At the same time, stand your ground, especially if the reviewer is trying to rush through what you consider to be salient information, and maintain direct access to the reviewer so you can fully address the case.
Immediately after the peer-to-peer review, document the call and summarize the conversation. If the payer’s representative requested additional information, send it promptly. In addition, request documentation of the reviewer’s decision, whether they overturned the denial or upheld it.
In the case of the latter, you can refer to the insurer’s policies to see what additional appeal options are available, such as written resubmissions and external independent reviews.
Missing deadlines, failing to provide quantitative data, and becoming defensive or condescending during the conversation are among the common pitfalls physicians need to avoid in peer-to-peer reviews. A list of potential stumbling blocks includes:
A peer-to-peer for insurance is a scheduled phone call that occurs as part of the insurer’s review process after a denial of coverage. The ordering physician typically speaks with a medical director or another licensed physician reviewer to explain the medical necessity of the recommendation and seek an approved outcome.
In healthcare, P2P usually stands for peer-to-peer review, a phone call in which a physician is trying to persuade a medical professional representing a payer to overturn a denial of treatment. However, it is sometimes used to refer to an internal peer review, in which hospital, clinic, or practice staff assess a colleague’s performance or actions.
Peer-to-peer reviews do not directly influence a physician’s medical malpractice coverage. However, a plaintiff could use inadequate advocacy for the patient in a P2P review to support claims of medical negligence or malpractice, especially if a weak record is cited after prior-authorization delays affected the patient's care.
Alternatively, a defendant could use a physician’s strong advocacy in a peer-to-peer review to mitigate any liability, and thorough documentation of how the physician sought to explain the medical necessity of the treatment to the reviewer can help show appropriate advocacy.
To improve their chances of overturning an insurer’s denial in a peer-to-peer review, physicians first need to understand and directly address the reason the treatment was denied and be ready to explain the treatment decision to the insurer’s reviewer.
They then must gather all relevant documentation and outside data, including clinical notes, charts, lab results, imaging studies, records of prior treatments that proved ineffective or are contraindicated, and specialty guidelines and peer-reviewed articles, so the supporting materials help the reviewer make an informed determination based on relevant expertise.
With that information they should draft a brief opening statement for the call. Physicians also need to maintain a respectful, professional, but firm demeanor throughout the conversation.
No, physicians cannot bill insurers for the time spent researching and conducting peer-to-peer reviews. P2Ps are considered administrative requirements rather than patient care.
Payer-to-provider peer-to-peer reviews have minimal bearing on medical malpractice insurance coverage. However, attorneys can subpoena recordings of P2P reviews and notes regarding PA requests, as well as the insurer’s determination on the request.
Further, plaintiffs can use them to strengthen claims of negligence or malpractice, while defendants can use them to mitigate a physician’s liability.
Maintaining strong documentation of P2P reviews and subsequent appeals is one way to help protect your practice, especially if a physician later appeals to the health plan or an external reviewer.
Carrying the right malpractice insurance is another. Indigo can help you find the right insurance coverage for your needs.
Contact us today to learn more.
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