Medical Peer Review – Frequently Asked Questions

Hello, my name is Jessica. I’m the Solutions Manager with Managed Outsource Solutions and I’m here to talk to you about some frequently asked questions on medical peer review.

Medical Peer Review can be referred to as a performance assessment through which physicians’ clinical performances are evaluated by their peers. In this process, everything ranging from medical charts of the patients to medical notes to billing procedures of the physician is reviewed. This is performed by a team of multiple physicians, by administrative committees and ethics committees. The core purpose of medical peer review is to enhance the treatment standards through patient safety and quality of care. This blog discusses some frequently asked questions on medical peer review.

00:50 What is a medical peer review?

Medical peer review, also referred to as clinical peer review, professionally assesses the work performance of “like” practitioners such as those with the same training, experience, and skill sets by using a formal evaluation system. This is a quality control mechanism seen in hospitals and large private practices.

On the other hand, insurance payers also conduct clinical peer reviews. However, the intent differs from that mentioned above. Payers focus on ensuring that the providers on their panels meet the quality standards with regard to treatment, coding, and medical necessity. This evaluation report is used as the criteria for the inclusion or de-selection of the physicians.

01:40 Why medical peer review is important for healthcare organizations

• To ensure compliance with federal and state statutes.
• For maintaining the facility accreditation with The Joint Commission, NCQA, and others.
• Medical peer review is important for receiving reimbursement from CMS and private payers.
• This can assist physicians or healthcare organizations to demonstrate the improvements or actions with outcomes.
• These evaluation reports are considered trusted data that enable physicians to know about required education, resources, and skill sets.

As far as individual physicians are concerned, medical peer review is a path to continuous improvement in the quality of care and services they provide. They can collaborate on best practices that bolster high-quality care for patients.

02:34 What are the processes involved in data collection and medical peer review?

• The medical staff services department and the quality department work in tandem to collect and provide the most appropriate data required for peer review processes.
• The overall management of the function is performed by a departmental or multidisciplinary peer review committee and multiple peer review committees. This involves reporting to the medical executive committee and the board.
• The peer reviewer in each case will be one individual or multiple individuals.
• The peer review is completed retrospectively and concurrently with the provision of care.
• Key performance indicators (KPIs) of each physician are looked at to help practitioners to improve the quality of care.

Proper medical record analysis crucial for medical peer review. A medical record review company can make the complex process of analyzing medical records faster in a cost-effective manner.

Thank you for listening and we hope you have a good day!