Peer Reviews for Health Plans – Why They Are Important The medical peer review process is a significant one that is performed to make sure that the clinical care provided is medically necessary and appropriate.
Medical peer review for insurance involves a physician-level review of the claimant’s medical records by a health plan to decide whether or not to uphold a denial of coverage for a specific claim. Typically, these reviews are conducted by a healthcare professional belonging to the medical specialty associated with the attending physician (s) who provided the medical services.
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The Peer Review Must Be Fair and Unbiased Generally, peer reviews are done by reviewing the medical records of claimants and once the evaluation is done, the reviewer will provide an opinion on the medical conditions or restrictions and limitations caused by the particular medical condition. The peer reviewer must be able to review the clinical information presented on the basis of the medical coverage guidelines of the health plan, use clinical judgment and provide an appropriate, unbiased decision. Accurate reviews help prevent excessive, inappropriate and medically unnecessary treatment while improving the quality of patient care and cost-effectiveness of treatment. The important thing is that the review should focus on the patient and his/her clinical situation. While health insurers do have physicians on their staff, they may not be specialists. Therefore, when the need for a specialist arises for medical claim review, the health plan may hire a medical review company. Also, cases such as workers’ compensation may require a physician of the same specialty as that related to the claim to conduct the peer review. In such cases also, smaller health insurers that may not have specialists on board may hire a third-party provider to ensure compliance. How Are Insurance Peer Reviews Useful? •
They help ensure that the patient receives medically necessary and appropriate services.
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Peer reviewers will make sure that their reviews are accurate by consulting the latest clinical guidelines supported by evidence-based medicine.
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Peer reviews bring increased transparency regarding the claim to payers and health professionals.
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Unprejudiced,
evidence-based
coverage
determination
will
improve
patient/health plan member’s satisfaction. •
Enhanced quality of care and patient safety.
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Reduced liability for the health plan since board-certified specialists belonging to the same or similar field of service as the attending physician.
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Hands-on risk management helps reduce risk.
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Minimal medical errors and adverse events.
What the Attending Physician Needs to Consider On the part of the attending physician, here are a few things to consider. •
Review the claim denial letter carefully to understand why the requested service was denied. It will also explain the appeals process.
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Ensure that the service denied is what was actually requested.
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It is vital to confirm that the request was accompanied by accurate documentation. Often, lack of information is what leads to claim denials. Therefore, the attending physician must make sure that the most recent medical records have been submitted for review.
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Review the health insurer’s medical coverage guidelines for the service requested. You can find these details on the insurance company’s website.
The medical peer review process is a significant one that is performed to make sure that the clinical care provided is medically necessary and appropriate. It helps avoid excessive medical costs while also providing the required patient care. Physicians treating patients must be knowledgeable regarding the medical coverage guidelines for the payors so as to avoid claim denials.
www.mosmedicalrecordreview.com
918-221-7791