Peer-to-peer review should be the strongest point in a utilization management (UM) program. It’s both an educational and collaborative conversation where a treating physician and a specialty-matched, qualified physician reach a determination together, grounded in a member’s real-world circumstances.Â
However, many programs struggle to deliver on that design. More than 1 in 3 physicians report that prior authorization (PA) criteria are rarely or never evidence-based and only 16% of physicians who take part in peer-to-peer reviews say the health plan clinician was appropriately qualified. The concept isn’t broken, but for many programs the execution isn’t matching the intent.
What Peer-to-Peer Review Is For
When the initial UM review applies criteria to available documentation, the peer-to-peer conversation adds clinical context that documentation alone can’t capture, such as why a member needs this dosage, reasons an alternative won’t work, or what’s already been tried.
Done well, peer-to-peer review is a clinical safety net. When two physicians can discuss the nuances of a member’s case and clinical evidence, inappropriate adverse determinations go down, and treating physicians have confidence that the process was substantive, not just procedural.
Done poorly, peer-to-peer is a scheduling hurdle that ends in a five-minute call with a generalist reviewer who can’t meaningfully evaluate the case. This version doesn’t reduce inappropriate determinations. It generates them.
Building a Peer-to-Peer Program That Works
The fix starts with two things: who’s doing the review and how quickly it happens.
Specialty-matched review means the physician on the plan’s side has current, relevant clinical expertise in the condition and treatment under review. When a pediatric neurologist calls about a complex seizure management case, the reviewer should be a pediatric neurologist, not a family medicine physician. That match is what makes the conversation genuinely peer-to-peer, and it’s what produces accurate determinations.Â
This is no longer just a best practice. A growing number of states, including Alaska, Nebraska, Illinois, New York, and Texas, now require same-specialty or same-or-similar-specialty reviewers for medical necessity determinations, and a bipartisan federal bill reintroduced in 2025 would extend that standard to Medicare, Medicare Advantage, and Part D plans. Specialty mismatch is turning from a quality gap into regulatory exposure.Â
It also fills a gap that’s easy to underestimate: the blind spots that inevitably creep into any physician’s knowledge base. Based on the pace of medical innovation, it’s nearly impossible for every clinician to stay current across every treatment protocol. A specialty-matched reviewer brings that current evidence into the conversation, keeping the treating physician informed on developments in treatment procedures and clinical guidelines relevant to the case.Â
When blind spots go unchecked, the consequences are specific: inaccurate diagnoses, ineffective treatments, exposure to unnecessary treatments, and unnecessary out-of-pocket costs for members and their families. A specialty-matched reviewer protects members from unnecessary or potentially harmful care by giving the treating physician the current evidence and clinical context needed to get the approach right. When the determination is right the first time, the member, provider, and plan all benefit.
For example, in a recent blog our team highlighted how pediatric psychiatric cases are uniquely complex. A 15-year-old with severe depression may also carry a trauma history, a learning disability, and a home environment that is destabilizing. Comorbidity is the norm in this population and untangling it requires a specialist reviewer who understands how these conditions interact developmentally. If this case required a peer-to-peer review, a pediatric subspecialist would be appropriate.Â
Turnaround time matters because a peer-to-peer review that takes three days to schedule is one that may not happen. The treating physician’s focus shifts to other urgent cases, the member waits, and the determination gets made without the conversation to inform it.
For health plans evaluating their peer-to-peer program — whether building internally or working with a review partner — a few criteria separate programs that work from programs that don’t.
- The process of specialty matching: A large reviewer panel is only useful if the matching methodology connects the right case to the right reviewer consistently.
- TAT reporting against real SLAs, not averages: Average turnaround can mask significant variation. Ask for distribution data on what percentage of cases meet the contracted timeline, and what happens to the ones that don’t.
- Confirmed accreditation: URAC dual accreditation (Health Utilization Management and Independent Review Organization) and NCQA certification are baseline indicators that the program meets national standards for clinical review quality.
- The escalation pathway: When a peer-to-peer conversation doesn’t resolve the case, what happens next? A defined, transparent process for escalation protects both the member and the plan. A growing number of states now require plans to publish their prior authorization requirements and timelines online, so ask whether a partner’s escalation path is documented and available to providers before a case ever reaches peer-to-peer.
- How technology is used: The right technology can accelerate scheduling, documentation, and case routing, but it never replaces clinical judgment.Â
The Conversation That Pays for Itself
Health plans that get peer-to-peer right do more than treat it as a regulatory checkbox. They treat peer-to-peer reviews as the highest-value conversation in their UM process — the one that protects members, earns physician trust, and gets the clinical decision right before it becomes an appeal. The plans that invest in specialty-matched review and hold their programs to real turnaround and quality standards ultimately see the difference on both sides of the ledger.
