Medical peer review helps insurers determine if a medical claim denial should be upheld or not. Peer reviews are usually done as a scheduled phone call between the insurer’s physician representative and the ordering physician. Peer review physicians will apply the health insurance plan’s coverage guidelines to the clinical information provided, and use sound clinical judgment to provide an appropriate decision.
To get the process done accurately, health insurers may use the service of a physician on their staff in-house or rely on an outside agency such as an independent review organization or a medical review company. Comparing in-house peer review and outsourced peer review can help insurers make the right decision.
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