Peer-to-peer (P2P) appeals can be challenging, particularly when a denial is based on medical necessity, level of care, insufficient documentation, or payer-specific criteria. However, each appeal is also an opportunity to better understand the clinical record, identify documentation gaps, and improve future denial prevention efforts.
You may be wondering why a guide like this is useful if you are already experienced with P2P appeals. The answer is simple: even experienced professionals become beginners again when circumstances, payer policies, clinical practices, or documentation requirements change.
Beginnings do not disappear; they happen again and again. Novices are just starting, while veterans have learned how to start over repeatedly. We all begin as beginners, and over time, we become perpetual “rebeginners.”
As a perpetual rebeginner, I would like to share some of my key “relearnings” from conducting peer-to-peer appeals for insurance denials.
1. Do Not Take Insurance Denials Personally
Insurance denials are business and clinical decisions, not personal attacks. It is important to remain objective and avoid allowing frustration or disagreement to affect your judgment during a P2P discussion.
A useful perspective comes from Michael Corleone in The Godfather: “Don’t hate your enemies, it affects your judgment.”
The same principle applies to payer interactions. Approach the physician reviewer professionally, focus on the facts, and keep the conversation centered on the patient’s clinical circumstances.
2. Build the Complete Clinical Story
Many denials occur because the payer reviewer does not have access to the complete clinical picture. The reviewer may be working from limited documentation or information that does not fully explain why a particular level of care was necessary.
Before the P2P call, gather the relevant clinical information and understand the patient’s entire story. Then present that information in a clear, logical, and compelling manner.
Remember, this may be the first time the reviewing physician is hearing the complete clinical story. Make sure your explanation is concise, clinically relevant, and easy to follow.
3. Recognize When a Denial Is Appropriate
Not every denial should be overturned. Some denials are appropriate and provide valuable opportunities for learning and improvement.
Use these cases as “teachable moments.” For example:
- Why should an inpatient admission have been observation status?
- Was the clinical documentation insufficient to support the level of care?
- Could the patient’s condition have been safely managed in the emergency department or outpatient setting?
- Was the medical necessity clearly documented?
In this sense, insurance denials can serve as a painful but useful form of clinical documentation improvement (CDI). They can reveal where documentation, clinical decision-making, or communication needs improvement.
4. Do Not Simply Repeat the Medical Record
A P2P appeal should not be a word-for-word summary of the patient’s chart.
Instead, conduct your own comprehensive review and explain why the information supports the requested level of care or service.
Identify the most important clinical facts, connect them to the patient’s condition, and explain how those facts support medical necessity.
Your role is not simply to read the record to the payer physician. Your role is to interpret the record and present the clinical argument clearly.
5. Review the Nursing Documentation
Do not limit your preparation to physician notes.
Nursing documentation can contain important information about the patient’s condition, including changes in vital signs, pain levels, oxygen requirements, functional status, responses to treatment, monitoring needs, and other clinical observations.
These details may provide additional evidence that is not clearly reflected in the physician’s progress notes.
6. Look Beyond the Current Hospitalization
Do not restrict your review to information documented during the current admission.
For example, suppose a patient is admitted with an elevated creatinine level, but the H&P does not reference a previous creatinine value. Reviewing the patient’s historical laboratory results may provide important context.
Previous laboratory values, imaging studies, diagnoses, treatment history, and prior encounters can help establish whether a finding is new, worsening, or chronic.
Old clinical information can sometimes make the difference between an upheld denial and an overturned denial.
7. Do Not Assume the Latest Progress Note Tells the Whole Story
Be careful when relying heavily on progress notes.
In some cases, today’s progress note may closely resemble yesterday’s note—or even a note from several days earlier. Copy-and-paste practices can result in outdated information remaining in the record.
Look for:
- Changes in the patient’s condition
- Updated laboratory results
- New treatments
- Changes in oxygen requirements
- New symptoms
- Medication changes
- New diagnostic findings
- Statements that may no longer accurately describe the patient
Always compare the progress note against the underlying clinical data.
8. Review All Vital Signs Yourself
Do not rely solely on the vital signs mentioned in physician progress notes.
Review the patient’s complete vital-sign record and look for abnormal values that may not have been specifically discussed in the physician documentation.
Also pay attention to units and conversions. For example, 37.7°C is approximately 99.9°F, so understanding both Celsius and Fahrenheit can prevent misinterpretation of clinical information.
A P2P reviewer should be comfortable identifying trends rather than focusing only on isolated values.
9. Thoroughly Review the Medication Administration Record
The medication administration record (MAR) can provide important evidence about the severity of a patient’s condition and the level of treatment required.
Look carefully for:
- PRN aerosol or respiratory treatments
- PRN IV medications
- IV fluids
- Pain medications
- Antiemetics
- Oxygen-related treatments
- Frequent medication administration
- Medications administered because of acute changes in condition
Some of these interventions may not receive significant attention in the physician’s progress note. However, when viewed together, they may help demonstrate the patient’s clinical needs.
10. If the Denial Is Upheld, Ask Why
If the reviewing physician does not overturn the denial, do not simply end the conversation.
Ask respectfully:
“What clinical information or circumstances would have supported inpatient status in this case?”
This question can help identify the specific issue behind the denial.
The discussion may reveal that additional clinical information, documentation, or clarification is needed. It can also help you understand how the payer’s physician reviewer is interpreting the case.
Most importantly, get the peer talking about the medicine. A productive clinical discussion can sometimes uncover information that was not apparent at the beginning of the call.
11. Track Providers With Repeated Denials
Maintain records of which healthcare providers are experiencing recurring denials.
Use this information to provide targeted, one-on-one feedback. If appropriate, also bring aggregate findings to departmental meetings so the organization can address recurring documentation or utilization issues.
The objective should not be to blame individual providers. Instead, use denial data to identify patterns and opportunities for education.
12. Track Denials by Provider, Reason, and Payer
A strong denial-management program should go beyond counting the total number of denials.
Track denials according to factors such as:
- Healthcare provider
- Denial reason
- Payer
- Service or procedure
- Level of care
- Medical necessity
- Documentation issue
- Frequency of occurrence
- Appeal outcome
This allows the organization to identify patterns and understand which payers are generating particular types of denials and why.
13. Understand the Reviewing Physicians’ Approach
Over time, you may become familiar with the styles of different payer physicians.
Some reviewers may be willing to consider the entire clinical picture, while others may follow specific criteria more strictly.
Understanding these differences can help you prepare appropriately. However, the goal should always be to present the strongest factual and clinical evidence rather than attempting to tailor or manipulate the case to a particular reviewer.
14. Know Your Hospital’s Payer Contract
Understand the contractual agreement between your organization and the insurance company.
For example, determine whether the contract contains provisions related to combining repeated admissions within a specified period, such as 30 days.
Do not assume that the payer representative’s interpretation is necessarily the final answer. When a contractual issue arises, review the actual agreement and involve the appropriate contracting or revenue-cycle team when necessary.
15. Understand Medicare Advantage Requirements
Know whether the Medicare Advantage (MA) insurer has a specific contractual arrangement with your organization and understand the applicable requirements.
If a reviewer upholds a denial based solely on a particular interpretation—for example, because the patient stayed only one midnight despite meeting the applicable criteria—review the circumstances carefully.
Depending on the situation, the organization may need to escalate the matter to the payer’s Medical Director, review the applicable contract, or pursue additional appeal rights.
When Medicare or Medicare Advantage requirements are involved, ensure that the appeal process follows the applicable Centers for Medicare & Medicaid Services (CMS) requirements and contractual procedures.
16. When the Case Has Merit, Use Your Appeal Rights
When you believe the clinical documentation and applicable requirements support the claim, do not automatically accept the initial denial.
Review the available appeal options, applicable deadlines, contractual requirements, and supporting documentation.
A denial should be evaluated based on the facts of the case—not simply accepted because the first review resulted in a denial.
17. Be Professional in Defeat—and Learn From Every Appeal
Not every appeal will be successful. When a denial is upheld, remain professional and respectful.
At the same time, understand your organization’s contractual appeal rights and determine whether further review is available.
Multidisciplinary rounds and P2P reviews can complement one another. Both processes provide opportunities to identify documentation problems, improve understanding of observation and inpatient requirements, and strengthen communication between clinical and revenue-cycle teams.
Insurance denials can therefore become opportunities for education and process improvement. Do not waste those opportunities.
18. Demonstrate the Financial Value of the PA Role
Denial management also provides an opportunity for physician advisors (PAs) and other clinical leaders to demonstrate their financial contribution to the hospital.
The clinical expertise involved in reviewing denials can directly affect reimbursement, prevent avoidable revenue loss, and identify opportunities to improve documentation and utilization practices.
To demonstrate this contribution, measure the financial impact of successful appeals.
19. Keep Detailed Records of Recovered Revenue
Maintain a detailed record of the denied charges that were successfully recovered through P2P reviews and appeals.
Depending on your organization’s reporting practices, consider tracking:
- Original denied amount
- Amount recovered
- Payer
- Denial reason
- Provider
- Type of service
- Appeal level
- Outcome
- Time required for resolution
These metrics can help demonstrate the financial impact of denial-management activities and support future process-improvement initiatives.
20. Share What You Learn
Do not keep the lessons from successful and unsuccessful appeals to yourself.
Share recurring trends, documentation issues, payer concerns, and successful appeal strategies with the appropriate clinical, CDI, utilization-management, coding, and revenue-cycle teams.
The value of a P2P program extends beyond recovering individual claims. The real opportunity is to use the information from those cases to prevent similar denials in the future.
Final Thoughts
Peer-to-peer appeals should not be viewed solely as an exercise in fighting insurance denials. They are also an opportunity to understand the clinical record more thoroughly, improve documentation, identify utilization-management issues, educate providers, and strengthen the organization’s revenue-cycle performance.
Every denial tells a story. Sometimes the story demonstrates that the denial was appropriate. Other times, a deeper review reveals clinical information that was overlooked or insufficiently communicated.
The key is to approach every case objectively, review the entire clinical picture, understand the payer’s requirements and contractual obligations, and learn from the outcome.