Medical Peer Review for Insurance – Frequently Asked Questions

by | Published on Mar 6, 2019 | Medical Peer Review

A medical peer review involves the review of a patient’s medical records by a physician, who provides an opinion based on the facts provided in those records. The peer review is presented in the form of a written report. An insurance company or payer that is not sure whether the treating physician’s diagnosis or treatment recommendations are correct may request for a peer review. In workers’ compensation cases, a peer review may be requested. The focus will be on the chief contributing cause of the patient’s condition. The peer review doctor would examine the medical records and determine whether the major contributing cause to the injury was the work-related accident or some other factor. The physician conducting the peer review will not have been involved in the case before the review and will be completely objective. The only goal of this reviewer is to ensure that appropriate care is being delivered/has been delivered to the injured person.

Let us examine some commonly asked questions regarding medical peer review and their answers.

  • Who requests a medical peer review for insurance?
    An insurance company, self-insured employer, third-party administrator, or managed care company may request for a medical peer review.
  • What are the qualifications necessary for medical peer reviewers?

    The reviewer must have at least the same credentials and qualifications as the treating physician. Ideally, he/she must be practicing in the same specialty as the treating physician.

  • Does a physician reviewer have to be licensed and have an active practice in the state where the claim occurs?

    Some U.S states require that the physician reviewers are licensed in the state wherein the claim occurs. Some states also require that they maintain an active practice in the state. Some states such as California do not require either of these two requirements. Since the aim of peer-to-peer discussion is to agree on the treatment plan, treating physicians typically prefer physicians who practice in the state and are aware about local practices.

  • How is physician peer review or medical peer review relevant in workers’ compensation?

    In workers’ compensation claims, physician peer review is used to determine whether a workers’ compensation patient is receiving appropriate care. Appropriate care is defined as that which is medically necessary, timely and provided in the proper sequence, and related to the work-related injury or illness.

  • What are the steps involved in a physician peer review?
    • The reviewing physician examines the patient’s treatment based on the latest evidence-based medical guidelines and statutory requirements to evaluate the effectiveness of the treatment.
    • The reviewing physician contacts the treating physician for a discussion of the case.
    • Based on this discussion and the review of all medical records, the reviewing physician prepares an objective and qualified medical report of the patient’s condition and future treatment.
  • How does the insurance company /payer make use of the peer review report?

    The insurance company/payer uses the report to make an informed and appropriate decision regarding the next steps to take. They would modify the treatment plan; continue the treatment plan without any change; or deny payment for certain types of treatment.

  • When does medical peer review occur in a workers’ compensation case?

    Usually, a workers’ compensation insurer may call for a peer review when they believe that the treatment has fallen outside of standard guidelines.A peer review should be used as part of a comprehensive managed care process and initiated only after telephonic and case management alternatives are tried. It can happen at any point during the claims process and can be used:

    • To determine medical necessity before the treatment is delivered (pre-authorization)
    • To determine the appropriateness of care during the treatment (simultaneously) or after a detailed review of the entire care continuum (retrospectively).
  • Can the peer reviewer stop payment on a claim?

    No, the peer reviewer does not have the authority to modify care or deny the claim. It is the insurer or payer that makes all payment decisions based on the peer review report provided to them by the physician peer reviewer.

  • What is the next step if the treating physician disagrees with the reviewing physician?

    If that happens, the claim would be brought before an Administrative Law Judge (ALJ) for mediation. In this process, the peer review report and the reviewing physician’s testimony can be used.

  • What is the difference between a peer review and an independent medical exam (IME)?

    In an independent medical exam a physician examines the patient and may also conduct a medical chart review to make a determination regarding the care provided to the patient.

    • While an IME provides an overview of the patient at that particular moment, a physician peer review provides a thorough evaluation of the patient’s condition over time.
    • Peer review uses the latest evidence-based medicine information to decide the appropriateness of the medical care provided. It involves a comprehensive medical records review comparing the treatment provided to state and occupational medicine guidelines. It also involves a discussion with the treating physician.
    • Peer review is faster and less expensive process than an IME.
  • What are the advantages of a medical peer review for insurance?
    As one of the most advantageous medical review solutions, a medical peer review for workers’ compensation and other insurance has the following benefits.

    • Reduces medical costs by identifying and avoiding costly and ineffective medical treatment.
    • Ensures that injured employees receive appropriate treatment, which speeds up recovery and helps them return to work faster.
    • It provides an irrefutable expert medical opinion to a person who may not be an expert in that particular medical specialty such as a nurse case manager or claims adjuster.
    • Provides the payer with an objective and credible medical opinion they can use when making payment decisions, when defending a case in mediation before an ALJ, or when settling a case.

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