What is a peer-to-peer review and should my doctor do one?
A peer-to-peer is a phone call between your doctor and the insurer's physician reviewer before or after a denial, and it is often the fastest way to reverse a medical-necessity or prior-authorization denial. Yes, ask for it, but it is not a substitute for the written appeal: request both, and make sure the call is on the record.
What to do, in order
- Step 1
Ask the insurer for the window
Most plans allow a peer-to-peer within a set number of days after the denial (often 5 to 14). Ask for the deadline, the number to call, and the criteria the reviewer applied, and send those to your doctor's office the same day.
- Step 2
Prepare the doctor in two minutes
The reviewer will read from the policy criteria. Give your doctor the criteria document and the one or two facts from the chart that meet each criterion. Calls that go criterion by criterion win; calls that argue in general do not.
- Step 3
Ask for a written outcome
After the call, ask the insurer for the decision in writing with the reviewer's name and specialty. If the reviewer was not in a relevant specialty, that goes in the appeal.
- Step 4
File the written appeal anyway
The peer-to-peer does not stop your appeal clock. File the appeal within the deadline; withdraw it if the call reverses the denial.
The deadline that applies
The peer-to-peer window is the plan's own and is short. The appeal window is at least 180 days from the denial on ERISA and ACA plans (29 CFR 2560.503-1; 45 CFR 147.136). For urgent care, ask for an expedited appeal, decided within 72 hours.
Calculate your date →Documents to gather
- The denial with the criteria named
- The insurer's clinical policy for the service
- The chart facts mapped to each criterion
- The written outcome of the call
Go deeper
Related questions
Can I join the call?
Usually not; it is physician to physician. You can supply the facts and the criteria beforehand.
The office says peer-to-peers never work. True?
They fail when the doctor argues in general. Give the office the criteria and the chart facts that meet them.
Does a failed peer-to-peer hurt my appeal?
No. The appeal is decided by a different reviewer on the written record.
Sources
Upload the denial letter. A senior reviewer reads it within 24 hours and tells you in writing whether it can be appealed and how. $0 upfront, 10% of what is recovered, nothing if we do not recover. Not a law firm.
Start a free denial review →