In healthcare, there are various types of peer reviews. Peer-reviewed journals ensure scientific papers are subjected to the academic scrutiny of expert peers. Peer review is also used to manage physician performance and ensure providers’ skills are held to the highest standards. A physician-level peer to peer review of medical records is often used by health plan professionals to determine whether or not to uphold a denial of coverage for a specific claim. These reviews are conducted by a healthcare specialist of the same field as the original medical claim.

For example, if the claim focuses on a test or procedure done by a podiatrist, a physician in the same profession is employed to review the case. Because of this, the process is sometimes referred to as a specialist-to-specialist review of the care.

What is Medical Peer Review?

Each physician-level medical peer review focuses on a patient and their clinical situation. The doctor reviews what steps occurred in the discrete and specific care episode of the individual. However, it’s not requested by a provider but rather a health plan or insurance company. Why? It could be that the entity doesn’t have an on-staff resource with experience in the specialty of the case or it involves a rare medical situation. Sometimes, health plans and/or insurance companies contract with an independent review organization (IRO) to harness their nationwide network of specialists and sub-specialists.

Reasons for Independent Medical Review

Many small to mid-sized health plans only have two or three physicians on staff, and those doctors often perform general medicine. When they encounter something like an oncology case, they may enlist the services of an IRO to have an oncology specialist review it. Or, they might be faced with conflict(s) of interest and want to avoid any appearance of impropriety.

Another factor that can prompt a health plan to utilize an IRO is compliance. In workers’ compensation cases, legislation that governs utilization reviews might require a physician of the same specialty to conduct the peer review. Once again, many smaller health plans don't employ a wide range of specialists and therefore use an IRO with doctors on staff from a variety of medical fields.

Appropriate and Medically Necessary Care

Overall, peer reviews like these focus on a patient receiving appropriate and medically-necessary services. Physicians consult the most up-to-date and industry accepted clinical guidelines, backed by evidence-based medicine, to ensure their reviews are accurate. In addition to streamlining the review process, licensed and credentialed clinical reviewers from a third-party vendor (IRO) benefit the healthcare industry by improving productivity and further securing the rights of patients. Benefits of physician-level reviews include:

  • Improved member satisfaction through an unbiased, evidenced-based external determination
  • Increased transparency for payers and providers
  • Improved safety and quality of care
  • Reduced liability through the utilization of external, Board-certified Specialists in the same or similar field of service as the original provider(s)
  • Decreased risk through proactive risk management
  • Reduced medical errors and adverse events

Partnering with an IRO 

During the process of an IRO physician-level review, the reviewing doctor looks at the case of the original clinician. The reviewer may speak to the doctor during the review to gather information that may not be included in the written record or forms. Occasionally, a form or part of a medical history may be missing or difficult to understand, so this open communication between the physicians helps to paint a more complete medical record and gives the best chance for the right decision to be made on the claim.

IROs offer physician-level review services that utilize evidence-based reporting to deliver high-quality results. In addition to adhering to strict compliance requirements, they have the capabilities and resources to deliver quick turnaround times and meet the appropriate state and federal guidelines and recommendations. Another advantage is their ability to offer unbiased decisions, eliminate conflicts of interest and ensure that each party is treated fairly through a resolution based solely on clinical documentation.

Investing in the services of an IRO that uses physician matching ensures reviews are managed with the highest level of knowledge and expertise using widely-accepted criteria. They offer immediate access to physicians and allied health care practitioners who are leaders in medical treatments and services. These doctors are active in medical practice, stay up-to-date on the latest evidence-based studies and services in their field of specialty and undergo a thorough credentialing process.

Contact us to learn more about the advantages of external peer-to-peer medical reviews.
What is a Peer to Peer Medical Review?