Peer-to-peer review
A peer-to-peer review is a conversation between the ordering provider and a payer's physician reviewer to discuss the clinical basis for a service the payer has questioned or denied.
Updated
A peer-to-peer review (often called a peer-to-peer or P2P) is a direct discussion between the provider who ordered a service and a clinical reviewer employed or contracted by the payer. It gives the ordering provider a chance to present the clinical rationale — the history, findings, and prior treatment — that the written request may not have fully conveyed.
It arises most often around a prior authorization the payer intends to deny, or has denied, on medical-necessity grounds. Some payers offer it before issuing an adverse determination; others make it part of an appeal after one.
The “peer” in the name is looser than it sounds. Where a Medicare Advantage organization expects to issue an adverse medical-necessity decision, the determination must first be reviewed by “a physician or other appropriate health care professional with expertise in the field of medicine or health care that is appropriate for the services at issue, including knowledge of Medicare coverage criteria” — but the regulation adds that the reviewer “need not, in all cases, be of the same specialty or subspecialty as the treating physician”. Expecting a subspecialist counterpart on the call is expecting more than the rule requires.
In practice
The opportunity is usually time-limited, and the window and process are set by each payer, so the applicable rules are the ones in that payer's policy or determination notice rather than a single industry standard. Because the reviewer decides from what the ordering provider can convey in the conversation, having the clinical record and the specific coverage criterion at hand is what makes the review useful.
Commonly confused with
- Appeal: A formal appeal is a documented challenge to a decision; a peer-to-peer is a clinical conversation that may precede or accompany one, depending on the payer.
- Prior authorization: Prior authorization is the advance-approval request itself; a peer-to-peer is a review step that can occur when that request is questioned or denied.