The term “peer-to-peer” sounds reassuring. In theory, it describes a process where two medical professionals of similar training and expertise discuss a patient’s treatment plan and determine the best course forward. In practice, for many physicians, it has become something very different: a conversation with someone who is neither a peer nor, in many cases, equipped to make an informed decision about the case at hand.

For patients, the phrase carries an implicit promise: that their doctor’s treatment recommendation will be reviewed fairly, by someone who truly understands the condition and the options. For physicians, it once meant an opportunity to advocate for a patient directly to another clinician who could weigh the evidence and offer a credible second opinion. The reality today is often far from that ideal. Too often, “peer-to-peer” means a call with an insurance company representative who may have a medical degree but in a completely unrelated specialty, or no relevant clinical background at all.

The consequences of this mismatch are not theoretical. They play out in delays, denials, and frustration for both doctor and patient. Imagine a cardiologist fighting for a complex heart medication being told “no” by a family physician who hasn’t treated advanced heart failure in decades. Or a neurologist’s request for a seizure medication being rejected by an orthopedist whose expertise lies in bones, not brains. The decisions made in these mismatched conversations directly affect patient care, yet they’re often made without the nuance that comes from real, hands-on experience in the relevant specialty.

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This erosion of what “peer” means undermines the entire process. True peer review is valuable. It’s how medicine grows, adapts, and checks itself. It’s why multidisciplinary teams work so well in complex cases: each specialist brings a depth of knowledge that complements the others. But when the “peer” in a peer-to-peer doesn’t share the same specialty, the same familiarity with current evidence, or the same firsthand experience treating the condition, the conversation is tilted before it begins.

The original justification for these calls was to prevent unnecessary or inappropriate care. In principle, that is a goal we all share. No doctor wants to prescribe a medication that won’t work or order a procedure that isn’t needed. But if the system is meant to ensure quality and safety, it should start with a definition of “peer” that reflects reality. A true peer is someone who has trained in the same specialty, understands the relevant clinical guidelines, and can evaluate a case with the same level of insight as the treating physician. Anything less is not peer review, it’s bureaucracy dressed in clinical language.

For physicians, these mismatched calls are more than an inconvenience. They erode professional autonomy, replacing the judgment of the doctor who has examined the patient with the opinion of someone who has not. They take time away from patient care.. hours spent on hold, transferred between representatives, and explaining complex cases to people who may not have the context to fully grasp them. And they contribute to burnout, feeding the sense that our expertise is constantly being second-guessed by those who do not share the same responsibility for outcomes.

For patients, the impact is even more direct. A “no” in a peer-to-peer call can mean waiting weeks or months for the right treatment, or never receiving it at all. It can mean settling for a second-choice medication that may be less effective or carry more side effects. It can mean losing trust in a system that seems to prioritize paperwork over people. Most patients never hear the details of these conversations; they just know their doctor “tried” and “insurance didn’t approve it.” The gap between what they believe is happening and what actually happens is wide, and it leaves them in the dark about how decisions affecting their health are made.

Fixing this requires more than tweaking scripts or adding more phone lines. It means redefining the rules to ensure that peer-to-peer actually means peer-to-peer. If an insurance company requires these conversations, they should be with physicians in the same specialty  (or, at the very least, in a closely related one) who are actively practicing and up to date on current standards of care. The review process should be transparent, with clear explanations for denials that reference the patient’s specific case, not boilerplate language that could apply to anyone. And it should happen promptly, so that care is not delayed unnecessarily.

Professional organizations, patient advocacy groups, and lawmakers all have a role to play here. We need policy changes that hold insurers accountable for the quality and relevance of their peer reviewers. We need to educate the public so that they understand what’s at stake, and so they can add their voices to calls for reform. And we need physicians to keep speaking up (not just in the exam room, but in public forums, media outlets, and legislative hearings) about what these conversations really look like and why they matter.

When “peer” is allowed to mean “any licensed physician,” the system fails both doctors and patients. It strips the term of its value, reduces medical decision-making to a checkbox, and diminishes the role of specialized knowledge in delivering the best care. But when “peer” is defined as it should be (someone with equivalent training), expertise, and current practice in the field, it becomes a safeguard for quality, a check on bias, and a genuine opportunity for collaboration.

The integrity of our profession depends on words meaning what they say. If we allow “peer” to become just another piece of insurance jargon, we accept a system that devalues the very expertise patients rely on. It’s time to reclaim the definition, and with it, the authority to make decisions grounded in true clinical knowledge.