Request a Physician Peer Review or Second Opinion if Medical Information Does Not Make Sense

6 Steps to Take When Asking the Adjuster for a Physician Peer to Peer Review

You can request a peer-to-peer or a peer review from your adjuster when occasionally the information provided to you by the doctor treating your injured employee just doesn’t make sense.

What’s the difference between a peer-to-peer or peer review: Here are the definitions:
1-Peer-to-peer is a discussion between two doctors usually about the treatment or condition of the injured worker.
2-Peer Review is one doctor reviewing the treatment or work of another doctor, but not a discussion. It is more of a second opinion of the file.

When you need to ask for a peer review, remember, it’s business. No one is accusing anyone of not doing a proper job and the company is not suggesting the employee is manipulating the treating physician to stay out of work or to achieve a settlement.

What the injury coordinator is doing is trying to make sense of the gray areas of medicine. Very often two physicians can examine the same patient and come up with two different opinions. You may want someone to review your claim file.

An injury coordinator is familiar with some of the medical information involved in complex employee injuries and will be on the lookout for things not understood or not adding up. If this occurs, there is nothing wrong with asking for a peer review, a second opinion on the medical portion of the file.

An email to your adjuster requesting a review can include:
1. All contact information, claim number and copy to the supervisor.
2. Explanation stating the company’s medical director has found discrepancies between the treating physician’s documentation and the doctor’s evaluation – this could include, but is not limited, to previous injuries having nothing to do with the workplace event.
3. A detailed explanation of the discrepancy, using proper medical terminology.
4. A note stating the employee’s treating physician’s diagnosis is keeping the employee from resuming work.

5. Ask for the claim is sent for peer review.
6. A request for you to remain in the communication loop.

Author Robert Elliott, executive vice president, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers’ Compensation costs, including airlines, health care, manufacturing, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. He can be contacted at: [email protected] or 860-786-8286.

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