I am a physician medical director in utilization management. I have spent more than a decade reviewing cases and participating in peer-to-peer (P2P) calls from the payer side. I am not writing this to defend the process. I am writing this because I watch physicians lose calls they should be winning, and the pattern is almost always the same:
The physician calls in frustrated. They had 10 minutes between patients. They did not review the chart beforehand. They open with some version of “I don’t understand why this was denied” and spend the next several minutes arguing from emotion instead of evidence.
I get it. The system is burdensome. The American Medical Association has documented it. You spend hours every week on prior authorization. The P2P call feels like one more obstacle between you and your patient’s care. But here is the thing: The P2P call is the one moment in this process where you have direct influence. And most physicians waste it. Here is what I wish you knew.
I Am Checking Boxes — Give Me Something to Check
When you call me, I have a criteria set open. InterQual, MCG, or a payer-specific clinical policy. Each one has specific clinical data points that must be met. When you talk about your clinical judgment or how long the patient has been suffering, I cannot do anything with that. I need dates. I need results. I need documented clinical findings that map to the criteria in front of me.
Before your next P2P call, ask one question: What criteria set was used for the denial? Then look at those criteria. The gap between what you submitted and what the criteria require is usually small and fixable. Address that gap on the call and the outcome changes.
Lead with Documentation, Not Conviction
“This patient needs this MRI” is not a clinical argument I can act on. “The patient completed six weeks of physical therapy documented on January 15, February 1, and February 15 with no improvement in radiculopathy, and developed a new foot drop on exam yesterday” is a clinical argument I can act on. Same patient. Same clinical picture. One version wins the call. One does not.
Pull up the chart before you dial. Find the dates. Find the results. Find the clinical change that makes this intervention necessary now. That is your script.
When You Lose, Ask This Before You Hang Up
“What specific documentation or clinical criteria would need to be met to approve this service?”
I am required to answer that. My answer gives you the exact roadmap for a successful appeal. Sometimes the gap is something simple that was in the chart but never submitted. Sometimes it tells you the criteria genuinely do not support the service, which saves you time on a futile appeal. Either way, that one question turns a failed call into actionable information.
Structure Beats Passion Every Time
The physicians who win P2P calls consistently are not the ones who argue the hardest. They are the ones who state the clinical question, present the history chronologically, reference the criteria, and address the specific reason for denial. It takes two minutes of preparation. Most physicians spend zero.
You would not present a case at grand rounds without preparation. Do not present one to a peer reviewer without it either. Know the criteria, lead with documentation, structure the call, and ask the right question when you lose. That alone will change your outcomes.
Besides the above, what tips have you found work for peer-to-peer calls? Share in the comments, and check out other's secret weapons for prior authorization here.
The author is a physician medical director in utilization management with more than 10 years of experience on the payer side of peer-to-peer review.
Image by GoodStudio / Shutterstock
