By Cheryl Ericson, RN, MSN, CDIP, CCDS
Physician Advisors frequently treat a peer-to-peer (P2P) call with a Medicare Advantage (MA) medical director as though it was an appeal. It is not. Nothing in 42 CFR Part 422 Subpart M (Grievances, Organization Determinations and Appeals) mentions P2P. Why not? Because P2Ps sit entirely outside the Medicare-regulated appeals process. MA plans are free to offer it, discontinue it, or use it however their contract allows, because the non-interference clause keeps CMS out of provider payment terms. Yes, P2Ps remain valuable as demonstrated by three scenarios.
P2P and Prior Authorizations (Pre-Service Reviews)
Beginning January 1, 2026, MAOs subject to 42 CFR 422.122 must decide prior authorization requests within seven calendar days, down from fourteen. That compression pushed some MA plans to stop offering P2Ps. Plans that keep option typically use it as an intent-to-deny mechanism. It starts with notification that the request does not meet inpatient criteria and will not be approved absent for more information. A P2P is usually offered within a 24 to 48-hour timeframe.
The P2P is not an appeal. It is a tool that allows the MA plan to obtain additional information through reasonable outreach before finalizing its initial determination (formally known as an organization determination). This is why MA plans may refer to these as an “educational” P2P. Provide additional clinical details and the plan can still approve inpatient care within the seven-day timeframe. Miss it, and the hospital is looking at a formal adverse organization determination and a reconsideration request (the formal term for a first level MA appeal).
P2P and Concurrent Reviews
Concurrent review runs on a longer clock, fourteen calendar days, because urgent and emergent inpatient services fall outside 422.122’s prior authorization rules. A patient already admitted and receiving inpatient-level care is a different situation than someone awaiting approval for an elective service.
The intent-to-deny mechanics are identical to those used with a pre-service request, except the timeline is extended to fourteen days unless an expedited review is requested. The MA plan’s UR team flags that it does not see inpatient criteria, offers a P2P to gather clinical justification, and either authorizes the stay or issues the Integrated Denial Notice. The extra week allows both payers and hospitals a little more breathing room.
P2P and Payment Reviews
Then there is the P2P that has nothing to do with coverage at all. A true payment review is a contractual issue and is not regulated by CMS. Payers will often use the term “payment review” or “contractual review” when making an organization determination, so hospitals must be alert to this tactic and push back. An initial determination asking for approval of an inpatient admission, especially if the hospital has yet to submit a claim, is an organization determination. It is not a payment or contract dispute and would fall into one of the above categories.
Aetna’s Level of Severity Inpatient Payment Policy authorizes inpatient urgent and emergent admissions of one midnight or more for contracted DRG providers but pays a lower severity rate on stays under five midnights unless MCG criteria are met. The admission itself is not denied; only the payment level is contested. A hospital that disagrees with the lower payment can request a severity review, A P2P-style discussion with an Aetna medical director. This P2P is a feature of the network contract, a negotiation tool, not a regulatory safeguard.
P2Ps Remain a Valuable Tool
Hospitals should continue to request P2P within their contracts as a mechanism to discuss cases before an adverse organization determination is issued. Used correctly, before an intent-to-deny becomes an adverse determination, or before a severity dispute becomes a stalled claim, it resolves a disagreement with a phone call instead of a formal appeal that consumes UR time; neither side wants to spend.
Knowing what type of P2P is being offered allows the Physician Advisor to employ the most strategic argument. Is it required outreach before the MA plan finalizes a coverage decision where CMS regulations set the tone? Or is the P2P a courtesy your contract happens to allow where the MA plan dictates rules of engagement. Brundage Group Physician Advisors are successful at preventing adverse determinations when given the opportunity through P2P; with a 61% success rate at receiving full inpatient payment when appealing Aetna low-severity inpatient payments.
Brundage Group can help. Not only do we have expert Physician Advisors, but we also offer operational assistance with scheduling P2Ps. Brundage Group has the experience and resources to support all P2P services. Outsource your Physician Advisor needs to Brundage Group, so P2P scheduling and clinical representation happen without disrupting bedside care. This allows your physicians to continue to treat patients without disruption for administrative reasons.
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