Why Outsource Medical Peer Review?

Strategic outsourcing of business processes prove beneficial for medical, legal and corporate entities, giving them intelligent solutions that help save time and resources. Medical peer review is one such process that insurance carriers, utilization review companies, third party administrators, independent medical examiners and private corporations can effectively outsource. The purpose of the review is to identify whether the medical services requested or performed are medically necessary. In this type of review there is no direct physician—patient interaction. Typically, the client sends the medical records to a physician other than the insured person’s treating physician or a medical review solutions provider, along with certain questions related to the records. The person reviewing the records will answer those questions and send it back to the client. If the peer review finds that a certain service was not medically necessary, the claim is likely to be denied.

Most states require insurance companies to follow explicit requirements when conducting a peer review. This is important; otherwise the peer review may be invalid. Patients who have been denied claims may proceed to challenge an unfavorable peer review ruling. This makes comprehensiveness and accuracy important elements of the peer review report. It should be professionally written and clearly identify why certain procedures/services/treatments are medically unnecessary. In this way, insurance fraud involving payments for unnecessary medical services or those that were never provided can be avoided to a large extent.

Services that Are Considered Medically Unnecessary

• Inpatient hospitalizations for medical services that can be provided safely and effectively on an outpatient basis.
• Cosmetic surgery
• Ongoing inpatient hospital care even when the patient no longer requires hospitalization
• An expensive procedure/treatment that is provided before first trying a less expensive and less invasive treatment
• Elective treatments/surgery opted by the patient

When to Outsource

• If you want to save money, time and labor
• You already have these services in-house, but would like periodic help when there is an overflow or backlogged cases
• When you want to ensure quality and accuracy

Outsourcing Benefits

The primary advantage of having an experienced medical record review company to provide peer review services is that they would ensure evidence based reviews that are comprehensive and address questions specifically related to the case. They work with all insurance and market types, and offer professional opinions for each case. Aspects evaluated include:

• Causality
• Standard of care
• Return to work concerns
• Diagnosis
• Restrictions and limitations
• Level of impairment
• Appropriateness of treatment
• Medical necessity
• Whether the service/treatment is of an experimental nature

The service is available for various insurance types including workers’ compensation and disability. A medical record review company providing peer review services will have the resources required to efficiently provide a complete, accurate and independent evaluation of all available medical records. A firm with many years experience in the field provides the service of highly skilled staff and a solid provider network. They can ensure accurate and timely answers to all queries the client may have regarding the medical necessity of a particular treatment or medical device; whether the person needs time off from work and so on.

An effective peer review provided by a reliable medical review services provider will:

• Provide an accurate, evidence-based justification regarding why the services in question were medically unnecessary.
• Reveal that the disputed services were not in agreement with generally accepted professional practice.