Insurance Peer Reviews – The Process and the Peer Review Report

by | Published on Nov 18, 2020 | Medical Peer Review

Peer reviews are utilized by healthcare providers and insurance companies to obtain detailed, evidence-based reports that provide objective and accurate answers to case-specific questions. The reports are prepared by physicians belonging to the specific medical specialty relevant to the case. If an insurer considers certain treatments to be unreasonable or unnecessary, they will object to them. In such cases, they will conduct a peer review to challenge the bill / claim for the medically unnecessary treatment. The reviewer need not see the patient for an examination. He only reviews the medical records and bills, and provides an expert opinion regarding whether the treatment is reasonable and medically necessary. The reviewer need not even contact the claimant’s treating doctor.

The Process

A peer review physician must be provided well-organized access to all details and information necessary that include:

  • All relevant medical records
  • Diagnostic images
  • Prior utilization reviews/recommendations
  • State-specific regulations
  • Guidelines relevant to each diagnosis

To provide an accurate report, the peer review physician would evaluate the following:

  • Causality
  • Diagnosis
  • Standard of care
  • Restrictions and limitations
  • Level of impairment
  • Return-to-work concerns

The Peer Review Report

The peer review report would answer questions related to the aptness of treatment, medical necessity, and whether the treatment is investigational or experimental in nature. Sometimes, the insurance company may undertake a peer-to-peer communication via a letter to the claimant’s treating physician(s) enquiring whether they agree with the peer review physician’s evaluation. The claimant’s physician(s) are required to respond within the specified time limit. Only after a response is received /the time limit has expired, will further processing of the claim happen.

  • In a fair and objective medical peer review report, the reviewing physician will provide appropriate answers to all questions raised by the insurer. Each answer would be justified with strong rationale.
  • To ensure that the insurer has a clear idea of all medical aspects, the peer review physician would also include all information regarding the various treatment and medical procedures the claimant has undergone before receiving a specific medical service eligible under the health plan.
  • Only the necessary inferences will be included in the report to avoid any kind of confusion.
  • The peer review physician would also ensure that his/her knowledge regarding the medical and legal aspects of the claim is clearly reflected in the review. This will enable the peer review report to be used as a valuable legal document for claim acceptance or denial.

If the peer review is not efficiently or objectively done, or if there are shortcomings in it and the claim gets denied, the claimant or his/her physician can request a copy of the review report from the insurance company. The claimant’s physician or a third-party physician can challenge the peer review produced by the insurer. If the claimant chooses to obtain legal support, the payer is required to provide a medical peer review report to support their decision to deny the claim. This report should contain all the details and accurate information regarding the reasons for claim denial.

Professionalism Is Important

Peer reviews are immensely significant from the viewpoint of making the right decision regarding the medical care provided to a patient. To have a comprehensive clinical understanding of the case, peer reviewers have to wade through a large number of medical records. Medical review companies provide the service of trained and expert reviewers to assist busy peer review physicians. Moreover, the final report will be cross-verified by experts to ensure accuracy and reliability. A health insurance company may find such services more efficient and quicker than when appointing an individual peer review physician to evaluate the claim. Given the importance of the peer review report as a decision-making tool in medical insurance claims, such professional services could be the better option.

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