Offer the peer-to-peer before the denial, not after. In much of utilization management, the conversation between a treating physician and a plan’s physician reviewer happens only once the plan has issued an adverse decision. By then, the patient’s care is already waiting and a denial notice is on its way. The call can do only one thing, which is try to talk the plan out of a decision it has made.
The same conversation, held before the decision, is a different conversation. It is a consult about a clinical question, and it often ends with the information the reviewer needed.
The order changes the conversation
After a denial, each side has a position. The reviewer is explaining a decision the plan has issued. The treating physician is contesting it. Reversing course is possible, but it now takes a formal step, such as a reopening or an appeal, and the request has to travel back through the process it just left.
Before a denial, the question is still open. The reviewer can say what the record does not show and what would change the answer. The treating physician can supply a missing test result or explain why a standard step was skipped. If the answer is still no, the physician at least knows exactly why before the notice arrives.
Physicians spend real time on these calls. In the American Medical Association’s survey of 1,000 physicians, 61% said they at least sometimes had to take part in a peer-to-peer review to get a request approved, and 56% said the number had grown over the previous 5 years. Only 15% said the plan’s reviewer often or always had the appropriate qualifications, and more than a third said the reviewer rarely or never did. Those numbers describe a process that physicians experience mostly as an obstacle after the fact.
What the rules already say
Texas has required the earlier conversation for years. Under Texas Insurance Code § 4201.206, when a utilization review agent questions the medical necessity of a service, it must give the provider a reasonable opportunity to discuss the treatment plan with a Texas-licensed physician before an adverse determination is issued. When a physician ordered the service, the discussion must be with a physician of the same or similar specialty.
Medicare Advantage rules approach the same goal from the other side. Under 42 CFR § 422.566(d), if a plan expects to issue an adverse medical necessity decision, the request must be reviewed before the decision by a physician or other appropriate health care professional with expertise appropriate for the services at issue, including knowledge of Medicare coverage criteria. The rule does not require a conversation with the treating physician.
There has also been confusion about what happens after a decision. Writing in February 2026, physician advisor Ronald Hirsch reported that many Medicare Advantage plans had told providers that CMS rules barred peer-to-peer discussions. CMS told him that its contract year 2026 rule “did not prohibit plans and providers from engaging in voluntary P2P,” and that a plan “may reopen the determination if they have received additional information.” The simpler path is to have the conversation while there is nothing to reopen.
A conversation after a denial is an argument. The same conversation before it is a consult.
How to build it into review
A pre-decision conversation has to fit inside decision deadlines that are now tighter. Since January 2026, Medicare Advantage plans and other payers covered by the CMS prior authorization rule must decide standard requests within 7 calendar days and expedited requests within 72 hours, as we described in our January analysis. That makes the design matter.
- Trigger it on the expected outcome. When a reviewer is leaning toward a denial, the case pauses and the treating physician receives an offer to talk, with a specific window, such as one business day for a standard request.
- Say what is missing before the call. The offer should name the criterion that does not appear to be met and the facts the reviewer could not find. Many calls become unnecessary once the physician sees the gap and sends the document.
- Match the specialty where it matters. The physician should know the reviewer’s specialty in advance. For specialized services, the reviewer should share it or a closely related one.
- Let the clock run if no one calls. If the physician does not respond within the window, the review proceeds on the record, and the notice states that the opportunity was offered and when.
- Write it down. Every conversation should leave a short record in the case file, showing what was added and how it affected the decision.
None of this slows a plan down much. Most requests never reach the point where a reviewer expects to deny them. For the ones that do, a short call before the decision often replaces an appeal and a delay in care afterward.
What we build for
We build tools health plans use in utilization review, and our rules make the pre-decision conversation easier to run. A clinician makes every denial, so a person is always in a position to pick up the phone. Every recommendation shows its reasons, so the reviewer can point the treating physician to the specific criterion and the specific facts in the record that met or missed it, instead of describing the problem from memory.
And every decision can be reconstructed, including the conversation. When a plan can show that a treating physician was offered a discussion and what changed as a result, the decision that follows is easier to defend and, more often than not, easier to accept.
A machine can say yes. Only a person can say no. Before that person does, the physician who knows the patient should have a chance to be heard.