No products in the cart.
MODULE 15: APPEALS & PEER-TO-PEER STRATEGIES
Section 4: Peer-to-Peer Call Preparation and Etiquette
A deep dive into preparing for and conducting a successful peer-to-peer discussion, covering case summarization, professional communication, and strategies for finding common ground.
SECTION 15.4
Peer-to-Peer Call Preparation and Etiquette
Transforming a Potential Confrontation into a Decisive Clinical Consultation.
15.4.1 The “Why”: The P2P as a Consultation, Not a Confrontation
To the uninitiated, the Peer-to-Peer (P2P) call is the most intimidating step in the appeals process. It is often perceived as a hostile cross-examination, an adversarial battle where a weary clinician must argue with a faceless corporate gatekeeper. As a Certified Prior Authorization Pharmacist (CPAP), you must aggressively discard this misconception and instill a new paradigm in your providers: the P2P is not a confrontation; it is a clinical consultation between two physicians. The medical director on the other end of the line is a licensed physician, often board-certified in a relevant specialty, who is tasked with a difficult job: ensuring that care is delivered in a way that is both clinically appropriate and consistent with the health plan’s policies and fiduciary responsibilities.
They are not the enemy. They are a colleague who has only seen a sterile, black-and-white snapshot of the patient through the initial paperwork. The P2P is the treating provider’s opportunity to add color, context, and the crucial nuances that no medical record can fully convey. It is a chance to explain the “why” behind the treatment decision—why this specific patient, with their unique history, comorbidities, and functional goals, requires this specific therapy at this specific time. Your role as a CPAP is to act as the provider’s chief of staff for this consultation. You will gather the intelligence, structure the argument, and prepare a concise, powerful briefing that enables your provider to conduct the P2P with maximum efficiency and impact. A well-prepared P2P is often the fastest and most effective way to overturn a complex denial.
Retail Pharmacist Analogy: The Pharmacist-to-Pharmacist Transfer Call
A new patient comes to your pharmacy asking to transfer a complex regimen, including a controlled substance, from another pharmacy. They hand you a crumpled, handwritten list of their medications. This list is the initial PA submission—incomplete and lacking context.
You would never dispense a high-risk medication based solely on this list. Instead, you pick up the phone and call the other pharmacist. This is the Peer-to-Peer call. Your tone isn’t accusatory. You don’t say, “Why would you dispense this?” Instead, you engage in a professional consultation:
“Hi, this is [Your Name], a pharmacist at [Your Pharmacy]. I have our mutual patient, John Doe, here to transfer his prescriptions. I have the list he provided, but I wanted to quickly touch base with you to get the full picture. For the oxycodone, can you confirm the original prescribing date and let me know if there have been any concerns with early refills? Also, I see he’s on an ACE inhibitor and an ARB; was that intentional for dual blockade or is one of those prescriptions old?”
The other pharmacist provides the crucial context: The oxycodone is for documented terminal cancer pain, and the ARB was discontinued six months ago but the patient forgot to cross it off his list. In this five-minute consultation, you have gathered the essential clinical information needed to ensure safe and appropriate care. You treated the other pharmacist as a trusted colleague, not an adversary. This is the exact mindset, tone, and objective of a successful P2P call.
15.4.2 Pre-Call Preparation: Engineering Success Before You Dial
Victory in a P2P call is determined long before the phone is ever picked up. Spontaneous, unprepared calls are the primary reason for failure. The provider, pulled from a busy clinic, fumbles through the EHR while the medical director waits impatiently. The key to avoiding this is a rigorous, pharmacist-led preparation process. Your deliverable in this process is a concise, powerful, single-page document we will call the “P2P Prep Sheet.” This document is the provider’s entire case on a single sheet of paper, designed to be read and absorbed in minutes and used as a script during the live call.
The P2P Prep Sheet: Your Single Source of Truth
The P2P Prep Sheet is the culmination of all your forensic work. It synthesizes the denial reason, the patient’s history, the failed therapies, and the clinical justification into a high-impact briefing document. It is not the entire medical record; it is a strategic summary of the most persuasive facts. You will draft this sheet, review it with the provider for 5-10 minutes before the call, and hand it to them to use as their guide. This single intervention can increase the success rate of P2P calls by over 50%. It transforms a stressful, disorganized conversation into a structured, confident presentation of the facts.
Masterclass Table: The Anatomy of the Perfect P2P Prep Sheet
| Section of Prep Sheet | Purpose & Content | CPAP’s Drafting Instructions |
|---|---|---|
| Patient Identifiers | Patient Name, DOB, Member ID, Appeal/Case #. | Place this at the very top. The provider must be able to state these immediately and correctly to start the call. |
| The 10-Second Summary | A single, powerful sentence encapsulating the entire case. Ex: “This is a 65-year-old male with treatment-resistant metastatic colon cancer who has failed two lines of standard chemotherapy.” | Draft this to be the provider’s opening line after introductions. It immediately frames the patient as complex and heavily pre-treated. |
| The “Ask” & The “Denial” | Request: [Drug, Dose, Sig]. Denial Reason: Quote directly from the letter (e.g., “Failure to trial preferred agent Drug X”). |
This focuses the conversation. It reminds the provider of the exact drug being requested and the specific hurdle that must be overcome. |
| Clinical Narrative & Key Data Points | A 3-4 bullet point summary of the most compelling facts. Ex:
|
This is the core of the argument. Extract these from your forensic review of the EHR. Use objective data (dates, scan results, lab values) whenever possible. This becomes the provider’s “talking points.” |
| Rebuttal to Denial (Step Therapy) | A clear, scannable, bulleted list of failed/contraindicated preferred agents.
|
Structure this to be an irrefutable, point-by-point dismantling of the denial reason. This is often the most important part of the entire prep sheet. |
| Anticipated Questions & Prepared Rebuttals | Brainstorm 2-3 likely questions from the payer and write down concise, evidence-based answers. Ex:
|
This is your advanced, strategic contribution. By anticipating the payer’s moves, you arm the provider with pre-formulated, confident responses, preventing them from being caught off guard. |
15.4.3 The Call Itself: Execution, Etiquette, and Persuasion
With the prep sheet in hand, the provider is armed for success. However, the execution of the call itself involves a specific set of communication skills and professional etiquette. Your pre-call briefing with the provider should cover these key points to ensure a smooth and effective consultation.
The First 30 Seconds: Setting a Collaborative Tone
The beginning of the call sets the stage for everything that follows. The goal is to be professional, respectful of the medical director’s time, and immediately take control of the narrative.
| Weak Opening | Why It Fails | Strong Opening (Scripted on the Prep Sheet) |
|---|---|---|
| “Hi, I’m calling about the denial for Jane Doe.” | Passive, incomplete, and forces the medical director to do the work of looking up the case. It starts the call on a reactive footing. | “Hello Dr. [Reviewer’s Name], this is Dr. [Provider’s Name]. Thank you for your time. I’m calling regarding patient Jane Doe, Member ID 12345, to provide some additional clinical context for our request for [Drug Name], appeal reference number XYZ987.” |
| “Why did you guys deny this drug?” | Confrontational and accusatory. This immediately puts the reviewer on the defensive and makes them less likely to be open to your argument. | “I have the denial letter in front of me, and I’d like to directly address the concern raised about the patient’s trial of preferred agents, as I believe the full history wasn’t clear in the initial submission.” |
The Language of Collaboration and Persuasion
The words you choose have a profound impact on the tone of the conversation. The goal is to frame your points as shared clinical observations and align yourself with the medical director as a fellow problem-solver working in the patient’s best interest.
Words and Phrases to AVOID in a P2P Call
- “Your policy…” (Sounds accusatory). Instead, say “The plan’s policy…”
- “You guys always…” (Generalizes and sounds hostile). Stick to the facts of this specific case.
- “Obviously…” or “Clearly…” (Can sound condescending).
- “This is ridiculous/insane/unbelievable.” (Emotional and unprofessional).
- “You have to approve this.” (Demanding). Instead, say “Based on this data, we feel the medical necessity is clearly established.”
Words and Phrases to USE in a P2P Call
- “To provide some additional context…” (Positions you as a helpful colleague).
- “I’d like to highlight a key finding from their recent scan…” (Draws attention to critical evidence).
- “I share your concern about…” (Finds common ground). E.g., “I share your concern about the potential side effects, which is why we have a robust monitoring plan in place.”
- “What information would be most helpful for you to overturn this decision?” (Direct, collaborative, and shows you want to meet their needs).
- “From my perspective as their treating clinician…” (Asserts your unique, direct knowledge of the patient).
15.4.4 The Art of the Clinical Pivot: Responding to Objections
Even with perfect preparation, the medical director may raise valid questions or objections. This is a critical juncture in the call. A successful provider doesn’t get defensive; they see these questions as an opportunity to provide further clarification and reinforce their argument. The key is to “pivot”—acknowledge the concern and then use it as a bridge to a stronger clinical point. Your “Anticipated Questions” section of the prep sheet is the training ground for this skill.
Masterclass Table: Common P2P Objections and Strategic Pivots
| Medical Director’s Objection | Defensive (Weak) Response | Strategic Pivot (Strong) Response |
|---|---|---|
| “The patient doesn’t meet the exact criteria in our policy. It requires an ejection fraction of <40%, and their last echo was 42%." | “Well, 42% is close enough. The policy is too rigid.” | “That’s a very sharp observation, Doctor, and I appreciate the detailed review. You’re correct the EF is 42%. However, the policy is designed to identify patients with symptomatic heart failure, and I want to provide context that the number doesn’t show. This patient has been hospitalized twice in the last six months for acute decompensation and has a pro-BNP over 5,000. Clinically, they are behaving like a patient with a much lower EF, which is why the guidelines support this therapy even in the HFpEF population.” (Pivot from the single data point to the overall clinical picture and guidelines). |
| “Why are you requesting the expensive brand-name drug when there is a generic alternative available?” | “The brand just works better.” | “That’s a fair question from a cost perspective. In this particular patient, we did trial the generic formulation last year and had to discontinue it due to a documented allergic reaction to an inactive filler ingredient, which is not present in the brand-name product. For this patient, the brand is the only safe option.” (Pivot from cost to patient-specific safety). |
| “The literature you submitted is just a small case series. That’s not very strong evidence.” | “It’s the only evidence there is!” | “You are absolutely right that we would all prefer a large Phase III trial. Unfortunately, for this ultra-rare pediatric cancer, such trials are not feasible. This case series, published by the world’s leading experts at [Top Institution], represents the current global consensus on the standard of care. Denying this would mean denying the patient the only therapy recommended by the foremost experts in their disease.” (Pivot from the limitations of the evidence to the established standard of care for a rare disease). |
15.4.5 Post-Call Protocol: Securing and Communicating the Outcome
The P2P call is not officially over when the clinical discussion ends. A professional closing and a meticulous post-call documentation process are essential to ensure the verbal agreement translates into an actionable approval and to create a clear record of the interaction.
- 1. Confirm the Outcome & Get the Number: Before hanging up, the provider must obtain a definitive verbal confirmation of the decision and, if approved, an authorization or reference number.
Script: “Thank you, Dr. [Name]. I’m glad we could clarify the clinical details. Just to confirm, you are overturning the denial and approving the [Drug Name]? … Excellent. Could you please provide me with the authorization number and its effective dates for our records?”
- 2. Document the Interaction Immediately: The moment the call ends, the provider should create a brief addendum in the patient’s EHR. This creates a time-stamped, permanent record of the conversation.
Example Note: “10/15/2025, 15:04: Conducted Peer-to-Peer review with Dr. Eva Rostova from ABC Insurance. Discussed patient’s clinical history, progression on prior therapies, and contraindication to preferred agents. Dr. Rostova agreed to approve [Drug Name] for 12 months. Authorization #123456 obtained. Will proceed with treatment.”
- 3. Close the Loop: The final step belongs to the CPAP. You must take the authorization number and ensure it is communicated to everyone who needs it: the specialty pharmacy, the infusion center, the billing department, and, most importantly, the anxious patient. This final communication is a crucial part of patient care, providing relief and confirming that a path forward has been secured.
