Peer Review Initiated By Specific Triggers
When a nurse case manager or senior nurse reviewer of a medical management company has any question about the appropriateness or value of the medical care provided by the employee’s medical provider, the nurse requests a peer review. Peer reviews also take place by referral of the claims adjuster when the adjuster does not have confidence the employee’s medical provider is taking the necessary action to speed the employee’s recovery and return to work.
The medical management company has a panel of doctors who are board-certified specialists in such fields as orthopedics, neurology, anesthesiology, internal medicine, pain management, occupational medicine, etc. To complete the peer review the better medical management companies often have in excess of 100 physicians on their panel of doctors and specialists in 25 or more medical fields.
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Peer Matching Significantly Increases Effectiveness of Review
Peer matching is the assignment of a specialist who has equal (or better) credentials to complete the peer review. If the doctor assigned to the peer review has fewer qualifications than the employee’s doctor, the employee’s doctor is not going to give much credence to the results of the peer review. For example, if the medical management company assigns a general orthopedic doctor to do a peer review of a shoulder specialist, the shoulder specialist may be inclined to dismiss the results of the peer review. On the other hand with peer matching where the peer review is completed by another shoulder specialist, the employee’s shoulder specialist is inclined to listen and cooperate with the peer review doctor.
The size of the medical management company is important from the stand-point of peer matching. If the medical management company does not have a full range of specialists, they often have a difficult time with peer reviews as they cannot do a proper peer matching. The larger the medical management company, the fewer the gaps when it comes to peer matching.
Specialists Collaborate to Determine Appropriateness of Care
To start the peer review, the nurse sends the medical and diagnostic reports to a physician on the medical management company’s panel of doctors. Depending on the nature of the requested review, often a specialist in the type of medicine being provided (orthopedic, neurologist, etc.) is assigned to review the medical information for the purpose of confirming the appropriateness and quality of the provided medical care.
The peer review is both an effective and productive tool to mitigate medical treatment issues. After the medical management company’s physicians thoroughly review the medical information regarding an injured employee, a teleconference takes place with the injured employee’s treating physician. By collaborating with the injured employee’s medical provider, a treatment plan based on medical necessity is developed and an agreement reached.
If the employee’s physician is too busy to discuss the employee’s medical treatment or for any other reason declines to discuss the medical treatment with the peer review physician, the peer review physician completes a report outlining the peer review physician’s findings and recommendations.
Quality of Peer Review Strongly Influenced By Expertise of Physician
The medical management company should be sure peer review physicians are trained in how to deliver their professional opinions in a non-adversarial way and as collaborators providing assistance. The peer-review physician solicits the employee’s medical provider’s thoughts and reasons as outlined in the medical treatment plan used with the employee. By discussing the clinical issues surrounding medical treatment, the peer review physician and the employee’s medical provider frequently come to a meeting of the minds on what is the best course of medical treatment for the employee going forward.
The quality of peer reviews is strongly influenced by the expertise of the medical management company’s physician. Successful outcomes to peer reviews require the panel doctor to be a fully credentialed, board-certified physician. When the medical provider discusses the employee’s injury with the panel doctor, the employee’s medical provider needs to have confidence that the panel doctor’s knowledge of the necessary medical treatment options equals (or exceeds) that doctor’s own medical knowledge.
When selecting a medical management company ensure they are URAC accredited. If you have questions about peer reviews or medical management in general, please contact us.
Author Michael Stack, CEO Amaxx LLC. He is an expert in workers’ compensation cost containment systems and helps employers reduce their workers’ comp costs by 20% to 50%. He works as a consultant to large and mid-market clients, is a co-author of Your Ultimate Guide To Mastering Workers Comp Costs, a comprehensive step-by-step manual of cost containment strategies based on hands-on field experience, and is the founder & lead trainer of Amaxx Workers’ Comp Training Center, which offers the Certified Master of Workers’ Compensation national designation.
Contact: [email protected].
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