When people hear the term “peer review,” they may associate it with an examination of some type of literature. The National Library of Medicine notes that “peer-reviewed journal articles have gone through an evaluation process in which journal editors and other expert scholars critically assess the quality and scientific merit of the article and its research. If an article passes this process, it’s published in peer-reviewed literature.

In health care, though, the goal of peer review is to improve the level of care provided by individual practitioners and monitor their performance. Recognized and accepted as a means of promoting professionalism and maintaining trust, it’s performed by internal or external peer review committees composed of physicians with varying backgrounds and disciplines.

Occupational oversight

As we explained in a previous blog, the peer review process was established more than 100 years ago to monitor physician behavior and define minimum standard of care requirements for hospitals and their medical staff. It changed in 1952 when the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), now called the Joint Commission, started requiring all hospitals in the United States to employ physician peer review.

The overall purpose of medical peer review is to improve patient safety and quality of care. According to the American Medical Association, the peer review process is intended to balance physicians’ right to exercise medical judgment freely with the obligation to do so wisely and temperately. Physicians consult the most up-to-date and industry-accepted clinical guidelines, backed by evidence-based medicine, to ensure their reviews are accurate.

Health care providers may opt for external peer review when they lack the appropriate internal resources, such as employees, time and specialty knowledge. They also might be faced with conflict(s) of interest, liability or a lack of proper policies and procedures for peer reviews. These reviews also are sometimes ordered by a health care organization’s medical executive committee (MEC), department chair, chief of staff or similar entity.

Hospitals must utilize peer reviews for existing doctors to maintain their privileges and for new physicians seeking privileges at the facility. Hospitals, doctors and administrators can request peer reviews of their colleagues if they are concerned about the quality of patient care. Some health care facilities use peer review of random or selected patients’ charts to identify problem areas.

Peer reviews often are conducted for physicians employed by hospitals and health systems to fulfill an accreditation requirement for the Joint Commission. However, they also can be administered for clinicians who work in a small physician practice, a surgical center or other health care entities. Peer review usually remains confidential within an organization and isn’t subject to disclosure or legal discovery in most states.

The American Association for Physician Leadership explains that the process should evaluate physicians over a period of six to eight months based on aggregate risk-adjusted data, as opposed to a single case or event. To ensure objectivity, peer reviews should only be conducted by physicians of the same specialty and/or subspecialty. Physician reviewers who are licensed and credentialed provide an advantage to the health care industry by improving productivity and further securing the rights of patients.

Peer review is not the same as peer-to-peer medical review, which occurs when a licensed and credentialed clinical reviewer studies a patient and his or her clinical situation and the steps which occurred in the discrete and specific care episode of the individual to determine an appeal on a medical claim. The process usually is requested by health plans and focuses on a patient receiving appropriate and medically necessary services.

Essential expertise

Although some health care entities possess the resources to conduct peer reviews internally, many invest in the services of companies that specialize in them. These businesses have the capability to deliver quicker turnaround times, meet the appropriate state and federal guidelines and recommendations, provide unbiased decisions and eliminate conflicts of interest. Plus, they’re able to match the most applicable board-certified physicians to the right cases, resulting in peer reviews that are managed with the highest level of knowledge and expertise using widely accepted criteria.

By integrating specialized technology into the peer review process, providers of these services are able to offer comprehensive data reports for trend analysis, improved transparency, HIPAA-compliant communication and increased data accuracy through decreased ineligibility. They’re also able to easily manage peer reviews remotely, an especially important competence during the COVID-19 pandemic.

MLS is a leading URAC-accredited national provider of peer review services with a recognized national network of physicians and allied medical professionals who service the entire United States. We offer peer review services in workers’ compensation, group health and disability for third-party administrators (TPAs), insurance carriers, utilization review organizations, hospitals, state and federal agencies and more. Sign up for our blog to receive regular updates on issues and trends affecting the health care industry.
What is the purpose of peer review in health care?