Peering Into Prior Auths: When Surgeons Should—and Shouldn’t—Engage in Peer‑to‑Peer

May 14, 2025 | by Brad Bichey

Deciding when—and when not—to engage in a peer-to-peer review is critical for surgeons navigating today’s increasingly complex prior authorization (PA) environment. Initial PA denials have risen sharply in recent years, amplifying administrative overhead and driving physician burnout. Before you consider opting out of more insurance panels or defaulting to another PA submission, recognize that not all peer-to-peer consultations are created equal: some should be avoided, others actively pursued.

The Stakes: Friction in Prior Authorization

Across the industry, PA requirements are blocking roughly 20 percent of necessary care—adversely affecting patient outcomes, threatening provider revenue, and straining device-maker support teams. To mitigate this, practices must adopt data-driven strategies and leverage artificial intelligence to streamline documentation, reduce denials, and make peer-to-peer engagements more productive when they are truly warranted.

1. Leverage AI to Produce Impeccable Notes

Most insurance payers now deploy sophisticated software—and increasingly, machine-learning models—to screen submitted records for grounds to deny. If an AI system is being used to block your authorization, you should use an AI solution at least as powerful to craft your documentation. A robust workflow includes:

  • Policy-Informed Note Generation: Feed the insurer’s policy language and your original clinical note into an AI tool that rewrites your note for perfect alignment with plan criteria.
  • ICD-10 and J-Code Optimization: Configure the AI rewrite to maximize the likelihood of matching required diagnostic (ICD-10 J-Code) and procedural criteria—targeting a ≥ 95 percent approval probability on first review.

By starting with “impeccable” notes, you’ll dramatically improve first-pass approvals and dramatically reduce the volume of denials requiring manual intervention.

2. Appeal Before Dialing for a Peer-to-Peer

Even with optimal documentation, a small fraction of PAs will still be denied. However, almost every denial can be appealed—and often does not require a live peer-to-peer conversation. If your AI-optimized note meets all policy criteria, submit a straightforward appeal request asking for human review:

Our review indicates all necessary criteria have been met. The AI that initially reviewed this documentation made a mistake. Please have a human clinical reviewer at [Insurer Name] conduct a manual review of the submitted documentation and reconsider this decision.

Reputable payers will frequently overturn such denials without needing to schedule a peer-to-peer. If a human review is still not sufficient and the plan insists on peer-to-peer, then proceeding with a live discussion is appropriate—and your chances of success will be high, since you can directly address the specific rationale cited for denial in your previously submitted documentation.

3. Decline Peer-to-Peer When Denials Are Unethical

After you’ve submitted a flawless note and pursued appeal, you may still encounter denials grounded not in missing information but in a payor’s unethical or cost-saving practices. In these scenarios, advise patients that scheduling a peer-to-peer is unlikely to change the outcome. You may offer the consultation as a paid service—clearly communicating the very low (< 1 percent) likelihood of reversal based on historical experience with that plan.

Differentiating AI “Hallucinations” vs. Unethical Denials

  • AI Hallucination: The denial cites absent or insufficient documentation—despite your note containing the required elements.
  • Unethical Denial: The reviewer explicitly disputes the clinical necessity (e.g., “Imaging findings do not meet criteria”), indicating a policy-driven or cost-saving agenda.

When you detect patterns of misrepresentation, selective disregard for patient need or safety, or overt cost-containment language (“insane,” “rubber-stamp”), it’s generally not worth your time—or the patient’s—to pursue peer-to-peer discussion.

Key Take-Aways

  • AI-First Documentation: Use advanced AI tools to align clinical notes precisely with payer policy language and coding requirements.
  • Appeal Before You Call: Submit a human-review appeal on any denial of a perfectly documented PA; many payers will reverse without a peer-to-peer.
  • Strategic Peer-to-Peer: Reserve live discussions for cases where a human review still denies, and where the denial rationale is clearly rooted in documentation rather than cost-containment.
  • Avoid Unethical Battles: Decline peer-to-peer in the face of pattern denials or overt cost-saving language—and consider a paid consultation model for transparency.

By adopting AI-driven note preparation, pursuing targeted appeals, and selectively engaging in peer-to-peer reviews, surgeons and the device companies that support them can reduce administrative burden, protect revenue, and focus on what matters most—delivering high-quality patient care.

Fire up!