Medical peer reviews are very important from the point of view of health insurance coverage. Though health plans receive a great deal of ire from providers and patients alike for claim denials based on the peer review process, it cannot be denied that such reviews are necessary to combat fraud and contain healthcare costs. Mostly, confusions associated with medical claims arise when the claimant or the insurer presents incomplete or improper medical reports. Such problems can be avoided if the peer reviewer provides a well-prepared report and makes all medical aspects clear for the attorneys, insurers and claimants.
Why Go for a Peer Review?
When a doubt or ambiguity arises with regard to a medical insurance claim, a review of the medical records may not be enough to convince the insurer that the claim is genuine. In such an instance, a medical peer review may be conducted by a physician employed by the insurer. This review is conducted mainly to decide whether the medical services provided by the treating physician were medically necessary. Medical treatments that are investigational or experimental are not usually reimbursed. Since there is no patient-provider relationship involved in an insurance peer review, it is expected that the review is unbiased.
How does a peer review work? Consider an imaging service that the patient has undergone for which he/she has claimed insurance reimbursement. The claim sent to the insurer will be accompanied by the relevant documents and medical evidence. To ensure the claim is genuine, the insurer may call for a reverification via a radiology peer review. For this, the insurer will send the imaging records, and other relevant medical documentation to the medical peer physician and ask certain questions regarding the necessity of the specific service. After reviewing the records, the physician will prepare answers to the insurer’s questions. A negative review or comment on the part of the peer review physician could lead to claim denial.
When a claim is denied based on a review by a peer physician, the claimant may seek legal counsel. In that case, the insurer will have to support their denial decision with appropriate medical peer review report containing the actual reasons for claim denial. The peer review report of the insurer could be challenged by the patient’s treating physician. A third-party physician could be appointed in that case to conduct another review so that a proper decision can be arrived at.
Features of a Reliable Peer Review
Let us consider the features that distinguish a reliable peer review.
- Complete and unambiguous: A good peer reviewer will answer all the questions posed by the insurer. He/she would substantiate their answer with the rationale and reasoning used to arrive at the final premise. There will be no ambiguity whatsoever in the answers provided. There will be no unanswered questions either, so that nothing is left unsaid.
- No unnecessary elaborations or answers: A review report that contains uncalled for explanations and views can confuse the insurer. A good report will not contain any such inclusions.
- All treatment details will be included: A dedicated peer reviewer will ensure that all details regarding the treatments and other medical procedures the claimant underwent before getting a specific treatment eligible under the health plan are clearly listed. This is vital to help the insurer understand the entire scenario.
- Demonstrates the legal and medical knowledge of the reviewer: Needless to say, for a peer review physician to produce an unbiased and authoritative review, he/she must be knowledgeable about the contractual language of the plan and the various medical aspects involved. Only such a review can act as a helpful legal document whether for claim denial or acceptance and clarify everything for the claimant, the physician, and the attorney.
Insurers mostly prefer associating with a company providing peer reviews as a service rather than partnering with an individual physician. This is primarily because such companies will have expert reviewers to prepare the review report and the final report will undergo multiple verification checks by experts to ensure accuracy and clarity. This will help the insurer arrive at a fair decision quickly and also ensure minimum hassle to patients who actually need certain medical services.