The Art of Peer-to-Peer: Clarification Over Correction in CMS Reviews

Across the country, there is considerable variability in how peer-to-peer (P2P) review processes are implemented within Medicare Advantage and Medicaid Managed Care programs.  This inconsistency often leads to confusion, dissatisfaction, and in some cases, non-compliance with CMS guidelines.  In today’s complex regulatory landscape, clarity is essential.  This article explores the regulatory boundaries and best practices for P2P reviews to support compliant, effective, and transparent clinical decision-making.

Peer-to-Peer Reviews:  Regulatory Framework

Once an organizational determination, such as a denial based on medical necessity, is issued that decision should remain unchanged unless a formal appeal is filed.  Once a final determination is made, no modifications to the clinical decision are permitted through informal discussions such as P2P reviews.  If additional clinical evidence is presented after that final determination, CMS mandates that this new information be addressed solely through the formal appeals process, not by reopening the case.  Reopens are reserved exclusively for correcting clerical or factual errors.  Any subsequent P2P discussion is intended only to help the requesting provider understand the rationale behind the adverse decision not to modify the outcome.

 Post-Determination Peer-to-Peer:  Educational, Not Revisional

Consider a Medicare Advantage or Medicaid Managed Care member who has had a service denied. After the decision is made, the provider initiates a P2P discussion, believing they can provide clinical details that will justify the approval they feel the case deserves.  Now, imagine the frustration this provider feels after taking the time to set up the appointment, participate in the call, and present their rationale, only to be told that the decision cannot be changed through this process, and they must instead go through the formal appeals process.  This situation is far from conducive to provider satisfaction.

 It is essential that providers understand that the purpose of the P2P call following an organizational determination is strictly to provide insight into the factors and criteria that led to the denial.  This discussion is meant to be educational in nature, aimed at clarifying the reasons behind the decision.  It is not an opportunity to present new clinical data or attempt to reverse the decision.  It is crucial that providers understand a post-determination P2P discussion is an opportunity for the plan to provide transparency and rationale of the decision-making process while making it clear that it is not a mechanism for reopening or changing the original determination.

Formal Appeals: The Correct Path for New Evidence

Should any new clinical evidence emerge after the organizational determination, the proper and only channel for review is through the formal appeals process.  This process is structured and multi-tiered beginning with a redetermination by the plan, automatically proceeding to an Independent Review Entity (IRE) if the decision is upheld and potentially escalating to an administrative law judge hearing or judicial review.  This is the required process according to CMS regulations.  New clinical evidence cannot trigger a case reopening; it must be addressed through the formal process.

Proactive Peer-to-Peer (“Soft Peer-to-Peer”):  A Promising Best Practice

There is an alternative scenario, which is quickly becoming best practice.  This method, that some in the industry have labeled a “soft P2P”, focuses on improving Member/Provider satisfaction, outcomes, and reducing appeals.  Using the “soft P2P” approach a physician reviewer would proactively contact the attending provider before issuing an adverse determination.  In this proactive setting, the reviewer is seeking clarification or requesting additional information while the case is still under review.  Because no final decision has been made at this stage, the P2P discussion can meaningfully impact the outcome.  This early engagement allows updated clinical information to be considered and helps the reviewer understand the attending physician’s decision-making process.  Such proactive interactions are both acceptable and encouraged, as they facilitate a more informed final determination, reduce adverse determinations, and appeals while increasing both provider and Member satisfaction. 

Conclusion and Recommendations

For Medicare Advantage and Medicaid Managed Care Members, once an organizational determination has been issued, the P2P process is used solely to clarify the rationale behind that decision; it is not a tool to reopen or alter the outcome.  Post-determination P2P discussions serve strictly as an educational review.  Any new clinical evidence that could alter the decision must be submitted through the formal appeals process.  Conversely, when a proactive or “soft P2P” discussion occurs before an organizational determination is made, it serves as a valuable opportunity to gather additional information and guide a more informed final determination, meanwhile improving Member and provider satisfaction and reducing appeals.  To ensure compliance, reduce appeals, and improve provider relations, healthcare organizations must clearly differentiate between the regulatory limits of post-determination P2P discussions and the strategic benefits of proactive, pre-determination engagement.

References:

Medicare Advantage (MA) Appeals:

42 CFR § 422.568 – Appeals and Grievances: Outlines the formal procedures for appealing decisions, including the submission of new evidence.   https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422/subpart-V/section-422.568

42 CFR § 422.629 – Reopening of Determinations: Permits reopening only to correct clerical or procedural errors, not to reassess clinical decisions based on new evidence.   https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422/subpart-V/section-422.629 

Medicaid Managed Care (MMP) Appeals:

42 CFR § 438.402 – General Requirements for Appeals: Establishes that decisions regarding medical necessity, coverage, or benefits must be formally appealed if new evidence is presented.   https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-438/subpart-F/section-438.402

42 CFR § 438.408 – Notice of Action and Appeal Rights: Specifies that decisions can be reopened only for correcting errors, not for reconsidering the clinical review.   https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-438/subpart-F/section-438.408