A medical peer review involves the review and analysis of an insurance claimant’s medical records written by his/her treating physician by another physician employed by the insurance company. This is primarily conducted to determine whether the services rendered by the treating physician to the patient were medically necessary. Claim denials occur when the peer review concludes that a certain service was not medically necessary.
A peer review is different from an IME or independent medical examination because it does not involve a medical examination of the patient. The peer review physician employed by the health insurer would review the treatment records of the claimant and create a peer review report. This report usually contains the peer reviewer’s medical opinions regarding the appropriateness and medical necessity of treatments provided.
- A peer review may be about utilization review, reasonable necessary treatment or similar issues.
- There is no physician-patient relationship involved. The insurance company would send the claimant’s medical records to the physician for review and medical opinion. The reviewing physician would answer the questions and send it back to the insurer.
Take the case of an insured person going for a knee replacement surgery. The insurance company would want to know whether the person qualifies under the contract to get such a service/treatment, especially because the expenses could run into several hundreds of thousands of dollars. Apart from being expensive, it could also have an impact on the welfare of the patients.
A good peer review would
- Answer all the questions asked by the insurer and provide the rationale regarding how the physician arrived at the particular answers.
- Provide details about the treatments the person would have to undergo before getting a particular treatment under the contract.
- Show the peer review physician’s knowledge about contractual language.
Shortcomings found in peer reviews include:
- Not answering all the questions
- Answering questions that are not there in the request
- Including irrelevant details that create confusion
Regulation 68 allows insurance companies to conduct a peer review to cross verify a no-fault claim. If an insurance claim is denied on the basis of a negative peer review report, the insurance company is required to release a copy of that report to the patient, his/her attorney and his/her treating physician if any of these parties request it. When claims are denied on the basis of peer reviews, they can be litigated. For the denial to be valid, the insurance company must show that the peer review report “set(s) forth a sufficiently detailed factual basis and medical rationale for the claim’s rejection.” The peer review can be challenged by a claimant’s treating physician by writing a medical rebuttal or by having a third-party physician perform a peer review.
Medical peer review service is included among the medical review services provided by a medical record review company and is useful for insurance carriers, utilization review companies, physicians and third party administrators among others.