Insurance Denials: A Comprehensive Review and Navigating the Peer Review Process

Insurance companies and third-party reviewers use the peer review process including prior authorization (PA) and the peer-to-peer (P2P) process to manage healthcare costs and ensure appropriate care, citing principles of value-based care. As the volume of initial denials increases, physicians face notable time burdens and increased administrative costs while patients can incur delays and possibly worse health outcomes. We aim to explore the legal and ethical framework of utilization management; examine the effect on treating physicians, patients, and reviewers; offer suggestions for navigating peer-to-peer reviews; and propose future directions and improvement opportunities.