ANSWERS · COMPLIANCE

What is a peer-to-peer review, and how do I win one?

A peer-to-peer is a call where the treating provider speaks directly with the payer's medical director to overturn a medical-necessity or prior-auth denial. You win it by being prepared and specific: know the payer's own coverage criteria, map your documentation to each one, and lead with the clinical facts that meet the policy.

ProviderBilling Lead

Step by step

1
Request it fast
Peer-to-peer windows are short, often just a few days after the denial — schedule it immediately.
2
Pull the payer's coverage policy
Get the specific medical policy the denial cites so you argue against the actual criteria, not a guess.
3
Map your chart to each criterion
Line up the documentation that satisfies each element of the policy before the call.
4
Let the treating provider make the call
The physician who knows the patient argues clinical necessity far better than staff reading from a note.
5
Document the outcome
Record who you spoke with, what was decided, and any reference number — you may need it for a formal appeal if the P2P fails.

Common questions

Who should do the peer-to-peer call?

The treating provider. The payer sends a medical director, and the strongest argument comes from the physician who made the clinical decision and can speak to the specifics of the patient's case.

What if the peer-to-peer doesn't overturn the denial?

You still have the formal appeal path. Document the P2P thoroughly — the clinical points you raised become the backbone of a written appeal, and the failed P2P often satisfies a required review step.

Where Volari fits: When a peer-to-peer fails or wasn't offered, Volari builds the formal medical-necessity appeal from the documentation — the part that outlives the phone call.

Related answers
How do I lower my practice's denial rate? →How do I reduce days in A/R? →How do I read an EOB or 835 remittance? →How do I know if I'm being underpaid by insurers? →How do I fix my prior-authorization workflow? →How do I survive a payer or Medicare audit? →

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