An Overview of Medical Peer Review for Health Plans

by | Published on Mar 25, 2020 | Medical Peer Review

Peer reviews are of different types in healthcare. In a healthcare organization, peer review is used to study physician performance and ensure that providers’ skills are maintained at the highest standards so that patients receive the best treatments and care. In the insurance industry, a medical peer review is performed to determine whether or not to uphold a medical claim denial. Such peer reviews involve a physician-level review of medical records, and are conducted by a physician that belongs to the same medical specialty relevant to the original medical claim.

What does a peer review for insurance focus on? Each review focuses on a patient and his/her clinical condition. Health plans and insurance companies sometimes utilize the service of an independent review organization or IRO that has a nationwide network of physicians belonging to all specialties and sub-specialties. Health insurers also work with medical review companies that provide the service of expert specialists and documentation staff. Typically, such a medical review is sought in the following instances:

  • Health insurers may have only a few physicians on staff and these doctors may be in the general medicine specialty. When a specialist is needed such as a cardiology specialist, the health insurer would enlist the service of an outside agency.
  • Health insurers may be concerned about conflict(s) of interest and prefer to avoid any appearance of impropriety.
  • To stay compliant. For instance, in workers’ compensation cases, legislation pertaining to utilization reviews may require a physician of the same specialty to perform the medical peer review. Small health plans with limited resources would use these external services that have doctors on staff from virtually all medical specialties.

What are the advantages of conducting a peer review with the support of an expert medical review organization?

  • Peer reviews are meant to ensure that a patient receives appropriate and medically necessary services. The reviewing physician would refer to the latest and industry accepted clinical guidelines, supported by evidence-based medicine to make sure that their review is accurate.
  • It streamlines the medical review process.
  • The health plan member is happy that the claim eligibility is determined by an external service provider and therefore will be evidence-based and unbiased.
  • Enhanced patient safety and quality of care.
  • Increased transparency for providers as well as insurers.
  • Reduced risk through proactive risk management.
  • Reduced liability via the use of external, experienced medical specialists belonging to the same specialty as the original provider.
  • Minimal medical errors and adverse events.

The peer review physician hired by the health insurer may contact the original clinician during the review process to obtain data that may be absent in the medical chart. When there is clear communication between the physicians, it is easier to arrive at the right decision regarding the medical claim. Peer reviewers would focus on ensuring the highest quality results by utilizing evidence-based reporting. They would also adhere to all compliance requirements, ensure quick turnaround times with their resources and capabilities, and also meet all federal and state guidelines and recommendations that are relevant to the claim. Most importantly, since their decisions are unbiased, all conflicts of interest are eliminated and it is ensured that the insurer as well as the claimant receives fair treatment through a determination that is made purely based on clinical documentation.

Medical review companies and independent review organizations providing peer review solutions make sure that the reviews are made with the highest level of expertise and knowledge using widely-accepted criteria. Insurers and health plans are provided access to physicians and other healthcare practitioners who are among the best in their field, and are active in medical practice. Moreover, these peer reviewers also stay abreast with the latest studies, developments, and services in their particular specialties to provide flawless services to their clients.

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