How Important Are Peer Reviews for Health Plans?

Author : MOS Medical Record Reviews | Published On : 05 Oct 2021

Peer reviews are performed when a face-to-face medical evaluation of the patient is either not possible or not required, and when there is some ambiguity regarding a diagnosis, injury, medical necessity, or level of impairment. Health insurers and healthcare providers both benefit from an accurate medical peer review process. The reviewer/reviewing physician prepares comprehensive evidence-based reports that provide objective and accurate answers to questions that are specific to the claim. The report is prepared based on the review of the pertinent medical records and bills, and an expert opinion is provided whether the treatment is reasonable and medically necessary. Prior utilization reviews and recommendations, state-specific regulations and each diagnosis related guidelines are considered when the review is done.

What are the various aspects studied during a peer review? 

  • Causation

  • Concerns regarding the claimant’s return to work

  • Limitations and restrictions

  • Level or extent of impairment

  • Standard of care

  • Appropriateness of treatment

  • Medical necessity

  • Whether any treatment or service provided is experimental or investigational

These reviews are very useful and requested for disability, workers’ compensation and health insurance plans. Typically, an independent specialty medical review that is a subset of peer review is required in instances such as the following.

  • Is the procedure provided experimental or investigational?

  • Is the treatment provided/proposed medically necessary?

  • Are there any pre-existing conditions as defined by the health insurance policy language?

  • Are the diagnoses and procedures properly coded?

  • Is there any upcoding or unbundling?

The peer review process involves a detailed medical record review, and for this medical record review to be smooth, the following things must be considered.

  • Proper medical record organization

  • List out factors that can be used to support causation, injury, functionality, limitations and restrictions, treatment advice, appropriateness of medical care provided, diagnosis and so on.

  • Identifying missing medical records that could be vital to the case.

  • Preparation of medical case chronologies that provide a clear view of all the medical encounters in a chronological order.

  • Medical summary preparation, highlighting all important facts of the case.

  • Quality checking, including checking for compliance and comprehensiveness of data.

For a peer review report to be effective, it has to be thoroughly researched, summarized and supported with appropriate evidence. It has to be fair and objective. The reviewing physician has to provide appropriate answers to all the questions raised by the insurer, with each answer supported by strong rationale. Moreover, all information regarding the various treatment and medical procedures the claimant has undergone will be included in the report. The peer review physician would also make sure that his or her knowledge about the medical and legal aspects of the claim is well brought out in the review report. This makes the report a valuable legal document. Also, to avoid any kind of confusion, only the necessary data or inferences are included in the peer review report.

Medical peer reviews are best prepared by a professional medical review company because the entire process will be speeded up and the output made available in fast turnaround time. They will provide quality, comprehensive, objective review reports based on the information contained in the medical records. In addition, they will adhere to strict compliance requirements, and meet all appropriate state and federal guidelines and recommendations. An unbiased review will help eliminate conflicts of interest and make sure that each party is treated fairly via a determination based solely on clinical documentation. Attorneys associating with an experienced medical chart review company benefit from peer reviews that are managed with the highest level of knowledge and expertise, employing widely accepted criteria.