I review your peer-to-peer calls. Here is why you keep losing.

I sit on the other side of your peer-to-peer call.

I am a physician medical director in utilization management. When you call to overturn a denial, I am the one listening. I have taken thousands of these calls over the past decade. I can tell within the first 30 seconds whether you are going to win.

Most of you lose. Not because the patient does not need the procedure. Because you do not know what I am looking at while you are talking.

Understanding the utilization management criteria

Here is what is on my screen. A criteria set. Usually InterQual or MCG, sometimes our internal policy. It has specific clinical checkpoints. Documented findings. Time-based thresholds. My job is to determine whether your patient meets those criteria based on what you tell me and what is in the chart.

That is it. That is the whole game.

But here is what most physicians do instead. They call me and say some version of “I really think this patient needs this.” They describe the clinical picture in their own words. They appeal to their judgment, their experience, their relationship with the patient.

I believe them. I usually agree clinically. But that is not what the criteria ask for.

Three strategies for winning peer-to-peer calls

The physicians who win do three things differently.

First, they ask me what criteria set I am using before they start talking. This one move changes everything. If I tell you it is InterQual, you can address the specific clinical checkpoints I need to satisfy. If it is MCG, the framework is different. If you do not ask, you are arguing blind.

Second, they lead with documentation, not narrative. “The patient completed six weeks of physical therapy documented on these dates with no functional improvement per these measures” wins. “The patient has been suffering for months and conservative treatment has not worked” does not. I need dates. I need documented findings. I need the clinical language that maps to the checkboxes on my screen.

Third, they know what to do when they lose. The best physicians ask a single question before hanging up: “What specific documentation or clinical criteria would need to be met to change this determination?” I have to answer that question. And when I do, I have just handed you the exact roadmap for your appeal.

Most physicians never ask. They hang up frustrated, tell the nurse it was denied, and move on. The appeal, if it happens at all, restates the same clinical argument that already failed.

The systemic gap in medical education

Nobody teaches any of this. I have looked. It is not in medical school curricula. It is not in residency training. There is no CME on P2P call preparation. Physicians are expected to navigate a process designed by payers, using criteria they have never seen, in a five-minute phone call squeezed between patients.

The system is not set up for you to win. But it is also not set up for you to lose. It is set up for you to meet criteria. The physicians who understand that distinction win their calls.

I am not here to defend the system. Prior authorization is burdensome, often counterproductive, and in many cases delays necessary care. The AMA’s data on physician time spent on prior auth is staggering and the trend is getting worse.

But while we argue about whether the system should exist, patients are waiting. And the physician who knows how to work within the system today is the one whose patients get their MRI tomorrow.

Closing the gap

Ask what criteria I am using. Speak to the documentation. And if you lose, ask me what would change my mind.

I will tell you. I always do.

The author is an anonymous physician.