A medical peer review for health plans is usually conducted to determine if a medical claim denial should be upheld or not. This review is performed by a physician that belongs to the medical specialty relevant to the original medical claim. It allows the ordering physician to discuss the adverse determination and present any new clinical information to the insurance company that could help reverse an adverse determination.
Peer reviews are usually done as a scheduled phone call between the insurer’s physician representative and the ordering physician. The peer review physician would apply the health insurance plan’s coverage guidelines to the clinical information provided, and use sound clinical judgment to provide an appropriate decision. Typically, health insurers may use the service of a physician on their staff or rely on specialty physicians working with a reliable outside agency such as an independent review organization or a medical review company. External support is usually sought when the health insurer doesn’t have a physician belonging to a specific medical specialty on their staff; or if the insurer is concerned about conflict of interest and wants to avoid any impropriety; or to stay compliant.
Let us now consider in-house medical peer review vs. that provided as outsourced solutions. When the peer review is done in-house, there are some advantages such as the following.
- Better supervision and control: If a task is performed by an in-house staff, he/she is accountable to you and therefore more attentive and receptive.
- Better communication: When the peer review physician is an in-house person, you can better communicate with him or her. Any problems or concerns can be openly discussed and solutions sought. The peer review process will proceed smoothly without major hitches.
- Better use of resources: If the insurer already has a medical peer review team in-house, external assistance need not be sought. They can make better use of the in-house team and needn’t incur additional cost related to hiring new staff.
Now, for the disadvantages of in-house peer review. The main drawback involved in utilizing in-house peer review solutions is that the physician may not be trained in the specialty related to the claim. This could raise allegations regarding the appropriacy of the review and related concerns. Another issue is that the number of claims may be too many and there may not be enough physicians to be assigned for the review process. This leads to increased workload on the physician, and the entire process could be very tedious and time consuming, also inviting the displeasure of the health plan member.
How about Outsourcing? Utilizing outsourced solutions for peer review does have its advantages.
- Increased accuracy for the review reports because the reviewing physician would be a specialist in his discipline and use the latest, industry-accepted clinical guidelines and evidence-based medicine to ensure maximum accuracy.
- Health plan member satisfaction is assured once he/she knows that the review is being done by an external agency and therefore be fair and fact-based.
- Streamlined medical peer review.
- Improved quality of care and patient safety.
- Liability risk is minimal.
- Minimal medical errors or adverse events.
- Increased transparency for insurers as well as healthcare providers.
- Assured data security and confidentiality because a reliable peer review organization would adhere to all applicable regulations such as HIPAA.
So, as we can see, peer reviews are essential to settle health insurance claims. Outsourcing the peer review process is more advantageous than having it done in-house as the foregoing discussion shows. The important thing is to find a medical review company or an independent review organization that is reliable and provides the service of qualified and experienced medical experts.
