Peer Review and CA Workers' Compensation - FAQ

Sunday, November 7, 2004 | 0

The following is second article in a two part series, by Mark Pew, Executive Vice President, Sales and Marketing of Professional Reviews Inc. (PRI). Mark advocates that peer review in the context of California workers' compensation is not only good for the system, but good for physicians as well. The first article in the series is a narrative discussion on peer review. This Part Two is a FAQ (Frequently Asked Questions) about the process.

by Mark Pew

1. What is physician peer review?

In general health care, physician peer review consists of the thorough examination of a patient's care by a physician or other licensed healthcare provider whose training is at least equal to that of the treating provider. The reviewer has not been involved in the case before the review and is completely objective. The reviewer's only goal is to ensure that appropriate care is being delivered or has been delivered.

2. What is the role of physician peer review in workers' compensation?

Physician peer review is a method used to determine if a workers' compensation patient is receiving appropriate care. Appropriate care is:
* Medically necessary
* Timely and delivered in the proper sequence
* Related to the work-related injury or illness (causality).

Physician peer review combines the reviewer's training and experience with science and commonly accepted treatment practices for a careful review of medical records. It involves examining the treatment in light of the latest evidenced-based medical guidelines and statutory requirements, and assessing the treatment's effectiveness. Then, the reviewing physician tries to contact the medical provider for a collegial discussion of the case. (The reviewers make at least three attempts to talk to the provider; there are times when the provider does not respond to the reviewer.)

The goal of physician peer review in a workers' compensation claim is to provide an objective and qualified medical report of the patient's condition and future treatment. The payer of the claim uses the report to make an informed and proper decision on the next steps the claim should take. These steps include:

* Modifying the treatment plan
* Continuing the treatment plan as it is
* Denying payment for certain types of treatment

3. What are the qualifications for peer reviewers? What is required in California?

The term "peer" indicates that the reviewer must have at least the same credentials and qualifications as the treating provider. To be effective, physician peer review should also match discipline to discipline, e.g., a chiropractor should review a chiropractor's care and an MD review an MD's care. Ideally, the review also matches specialty to specialty, so an orthopedic surgeon reviews another orthopedic surgeon's case and an ophthalmologist reviews an ophthalmologist's case. California does not require the specialty match, but does require the discipline match.

4. Do physician reviewers have to be licensed and maintain active practices in the state where the claim occurs? What is California's requirement?

Some states require that the physician reviewers be licensed in the state in which the claim occurs. Some also require that the physician maintains an active practice in the state, defining "active" by a prescribed number of hours over a given time period.

California does not require state licensure or practice domicile. However, the goal of the peer-to-peer discussion is to gain agreement on the treatment plan, and treating providers tend to be more receptive to physicians who practice in the state and understand local practices.

5. When does physician peer review occur in a workers' compensation claim?

Physician peer review should be part of a comprehensive managed care process and only come into play after telephonic or case management alternatives have been exhausted. It typically occurs when a red flag goes up indicating that the treatment has fallen outside of standard guidelines, which can happen at any point during a claim.

It can be used to determine medical necessity prior to treatment being delivered (pre-authorization). Physician peer review may also be used to determine the appropriateness of the care during the delivery of treatment (concurrently) or after a comprehensive review of the entire continuum of care (retrospectively). Many payers combine the efforts of utilization management, medical case management and claims case management to determine the use of peer review at the most effective point in the medical treatment process.

6. Who requests a physician peer review?

A payer (an insurance carrier, third-party administrator, self-insured employer) or managed care company may request the review.

7. Can the peer reviewer stop payment on a claim?

No. Neither the physician reviewer nor the peer review company has the authority to modify care or deny payment. The peer review report provides the payer with the information needed to make all payment decisions.

8. What if the providing physician disagrees with the reviewing physician?

The claim would then proceed to mediation before an Administrative Law Judge. The peer review report and testimony from the reviewer can be used in this process.

9. What are the alternatives to peer review?

A medical exam by an Independent Medical Examiner (IME) who has previously not been involved in the case is seen as an alternative in some states, albeit a significantly more expensive one. In California, in IME is further defined as QME (qualified medical exam) or AME (approved medical exam).

10. How does peer review compare with Independent Medical Exams?

An independent medical exam (IME) is a one-time event in which a physician examines a patient (and may also review medical records) and makes a determination on his or her care. It's more of a snap-shot of the patient's condition at that particular moment.

In contrast, physician peer review provides a thorough assessment of the case over time. Peer review uses the latest evidence-based medicine information to determine appropriateness of care and involves a comprehensive review of medical records, comparing treatment to state and occupational medical guidelines, and typically, a discussion with the treating physician.

Peer review is less expensive than an independent medical exam. The average cost for a comprehensive peer review is $210 to $380 while the average cost for a physical examination is more than $500.

More importantly, it is a faster process. The national average for the turnaround time on peer reviews is seven working days. IMEs take at least four weeks, on average. While waiting for the appointment the patient may be out of work and collecting indemnity (lost-wages) payments as well.

11. Why have Independent Medical Exams?

Independent Medical Exams are important tools in the managed care tool kit and necessary in some cases. However, they should be considered the step after peer review. Peer review can identify issues and narrow the focus on the medical exam, saving time and money.

12. What are the benefits of physician peer review?

Physician peer review:
* Reduces the medical cost of a claim by intercepting costly and ineffective treatment, or by changing the course of care through collegial discussion with a provider.
* Assures that appropriate treatment is delivered to injured employees, which speeds recovery and return to work;
* Provides an incontrovertible expert medical opinion to a person who is not an expert in that particular medical field, such as a claims adjuster or nurse case manager.
* Gives the payer a credible, objective, and certifiable medical opinion to use in making payment decisions, settling a case or defending it in mediation.
* Can confirm that appropriate care is being delivered.

Mark Pew, Executive Vice President, Sales and Marketing, PRI, can be reaced at (800) 442-1555, ext 3352, or by e-mail at mpew@prium.net.

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The views and opinions expressed by the author are not necessarily those of workcompcentral.com, its editors or management.