Insurance peer review is an important process when determining the claimant’s eligibility for medical insurance coverage. It helps ensure that the coverage is provided for medically necessary services and there is no fraud involved. Typically, the reviewing physician is one who has not been involved in the care of the patient and is completely objective. His/her major concern is to ensure that the care delivered is appropriate. The need for peer review also increases the relevance of medical peer review services that help with medical record review and eligibility determination.
Three important aspects of the peer review are:
- The standard of care for the particular treatment
- Whether that standard was followed, and if followed, how?
- If the standard was not followed, what medical reasoning or facts justified that deviation from the standard?
Peer Review in Workers’ Compensation
In workers’ compensation, medical peer review or physician peer review is utilized to find out whether the worker is receiving adequate care. This refers to care that is medical necessary, related to the work-associated injury or illness; timely; and provided in the proper sequence. Medical record review is carefully done to examine the services provided in the light of the latest evidence-based medical guidelines and statutory requirements. In workers’ compensation, an objective peer review report would help the payer make an informed and proper decision on the next steps in the claims processing – whether to modify the treatment plan, continue the treatment plan, or deny payment for certain types of treatment.
The peer review is typically a part of a comprehensive managed care process. Usually, it is triggered when there is an indication that the treatment has fallen outside of standard guidelines. It is used after telephonic or case management alternatives are exhausted.
- Insurers may use this review process to determine medical necessity before the treatment is delivered, during the delivery of treatment, or after a detailed review of the entire care provided – i.e. pre-authorization, concurrently or retrospectively.
- The payer, i.e. the insurer, third-party administrator, or self-insured employer, may request a peer review.
- The insurance peer review report is intended to provide the insurer with the information needed to make a payment decision. It is important to understand that neither the peer review physician nor the peer review company has the authority to modify care or deny payment.
- If the treating physician does not agree with the reviewing physician, the claim would be sent to an ALJ or administrative law judge for mediation. Here, the medical peer review report and testimony from the reviewer can be used.
Peer Review vs Independent Medical Exam
Many people are confused whether peer review and IME or independent medical exam are the same. They are not the same. In an IME, a physician examines the claimant and reviews the relevant medical records, and based on which determines his/her care. In some states, it is seen as an alternative to physician peer review. The physician peer review involves a thorough assessment of the case over a period of time. The latest evidence-based medicine information is used to decide on the appropriateness of care. The process also involves a comprehensive review of the medical records; the treatment is compared to state and occupational medical guidelines: and may also involve a discussion with the treating physician.
Benefits of Medical Peer Review
Here are the major benefits of a medical peer review.
- It helps reduce the medical costs of a claim by identifying costly and ineffective medical treatment, or by modifying care through discussion with the treating physician.
- It ensures that injured workers receive appropriate treatment. This helps speed up recovery and ensure a faster return to work.
- Peer reviews are reliable and provide an irrefutable expert medical opinion to nurse case managers, or claims adjusters who may not be experts in that specific medical specialty.
- Provides the insurer an impartial, reliable and certifiable medical opinion that can be used to make payment decisions, settle a case, or defend it in mediation.
For the peer review process to be unhindered and reliable, the peer review physician must have hassle-free access to all relevant information. This would include all applicable medical records, including prior ones; diagnostic images; guidelines related to each diagnosis; regulations pertaining to each state; and prior recommendations and utilization reviews.
It is important that the peer review is completed with the highest quality and accuracy. A provider of medical peer review services will have a formal QA process to make sure that the peer review report is accurate and reliable. It would be based on sound clinical reasoning that is apt and reliable from the viewpoints of diagnosis, relevant guidelines, and medical records. The report would answer all the questions posed by the insurance adjuster, provide the treating physician’s viewpoint when relevant, and meet all jurisdictional requirements.