How Does a Medical Peer Review Company Assist Physician Consultants?

A medical peer review company provides valuable support to physician consultants who need to review large-volume medical records. Consultant physicians are hired by health insurance companies to evaluate various claims filed by plan members. For instance, physician consultants may be hired to perform a medical peer review to evaluate the party’s case and the medical records that are relevant to the case in a long-term disability insurance claim. They identify, review, and extract important facts in the patient’s medical chart, facts that are important for medical and legal purposes. Physician consultants often seek medical review solutions to make the review process easier.

Here’s how a peer review company assists physician consultants.

Provides Medical Peer Review Assistance

Insurance peer review is part of the investigation of a particular claim. The health insurance company may consult with physicians and other healthcare providers about a case. A peer review can be performed in one of the following ways:

• The insurance adjuster schedules an IME or an independent medical examination. In this, a physician chosen by the insurance company will review the claimant’s medical records, perform an exam, and then write a report.
• The insurance adjuster chooses a physician consultant – this may be a doctor who works directly for the insurance company or an independent contractor.
  • Copies of the complete set of medical records are made available to the physician consultant.
  • The physician consultant reviews all the documentation, and may contact the claimant’s doctors to discuss the claimant’s conditions and treatments required.
  • Following the review, the physician consultant will prepare a report that summarizes the plaintiff’s medical conditions and provide an opinion about the claimant’s ability to work.

Provides Medical Records Analysis and Related Solutions

• A comprehensive review of the medical chart helps ensure that the patient received the right treatment for his/her health condition. Also, the review results help ascertain the medical necessity of various medical services provided to the claimant.
• This review is also vital when it comes to deciding on a fair claim settlement in medical litigation such as personal injury, medical malpractice, and product liability. While providing insurers with a clear understanding of the medical claim. An accurate review of the medical records can also bring to light any possible fraud.

The Process of Medical Record Analysis

• Medical record retrieval from various healthcare facilities and physicians
• The various components of the medical record are identified
• Information from the records are retrieved
• The information is collected and classified based on data type
• Data such as demographic characteristics, medical care received, diagnostic procedures, therapy notes, and treatment are captured and arranged in a chronological order
• All records, including imaging records and documents reviewed are listed
• All objective tests performed are enumerated
• The range of motion and outcome assessment study is quantified

Information from each medical record referencing the date of service, type of service, provider of service, and place of service is classified. The medical records are sorted and indexed, interpreted, summarized and classified appropriately. Once the records are properly organized, the information is reviewed for completeness, accuracy, and compliance. Missing records are identified. The information from the medical records is presented in an easy-to-follow format. An accurate chronology and timeline is developed for easy understanding of the sequence of events.

Physician consultants consulted in connection with medical negligence cases may need to review the medical chart for issues such as the following:

• Diagnosis and treatment
• Illegal or excessive prescribing
• Dishonesty
• Inappropriate examinations

The plaintiff’s medical records provide information that helps establish negligence, incompetence and gross negligence on the part of the treating physician.

• Negligence: This involves simple departure from the standard of practice; one act of simple negligence may not be sufficient to take action against a physician. Repeated negligent actions can have serious consequences.
• Incompetence: This is lack of knowledge or ability in discharging professional medical duties. If the physician is unable to recognize and act appropriately on symptoms, he/she may be considered incompetent.
• Gross negligence: This involves extreme departure from the accepted standard of practice. Physicians who do not perform basic diagnostic tests, do not recognize or act on common symptoms, do not use accepted effective treatments or diagnostic procedures, use outdated procedures, or do not refer a patient to a specialist when necessary, are guilty of gross negligence.

Medical Review Solutions Are Useful for Physician Consultants

Physician consultants serve in different capacities. They assist attorneys in determining the standard of care and medical negligence on the part of the treating physician. They serve as expert witnesses in criminal and medical malpractice lawsuits, and also provide testimony to federal panels for approval of new medications. Since medical record review is an important part of medical litigation, physician consultants will find support solutions very useful. When the tedious process of reviewing medical records is entrusted to reliable providers, physician consultants benefit from time saved, cost savings, and considerably reduced effort.