The Art of Creating a Physician Peer Review Panel, Part 1

| | Physician Peer Review

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Kats June Panel Article
Creating a Physician Peer Review Panel is like solving a puzzle – it comes together only after reviewing the landscape, discerning what is important, and identifying what resources are available. As in most industries, a problem or opportunity in the workers’ compensation arena first presents itself, then team members come together to share ideas and collaborate on possible solutions.

From my experience, creating a physician peer review panel usually involves focusing on three key areas:

  • geographical areas (i.e. jurisdictions where most of your business is performed)
  • client requests
  • contacts in the medical community
Once the “where” is identified it is necessary to define the types of physicians needed to support your business. In workers’ comp, the focus is based on specialties surrounding musculoskeletal injuries, such as occupational medicine, physical medicine and rehab, orthopedics, neurology and other specialties that often treat workplace injuries.

Next is the “who.” How do you know if a physician is qualified to perform peer review work? Many physicians think it’s an easy task because they treat patients daily – or did at one time. However, performing as a panel member may require a different skill set.

Think about the fact that a doctor is rarely challenged about his/her diagnosis or treatment plan when they present it to the patient. Based on the physician’s experience and confidence, patients do not typically question the treatment plan or recommendations.

However, in utilization review, physician reviewers are expected to question the treatment plan when it falls outside of guidelines. They are to question the efficacy of the treatment being proposed based on the clinical documentation. This includes an injured worker’s current and past treatment that has been submitted along with the request. It’s also helpful to have the mechanism of injury as part of the clinical documentation. And, keep in mind, the peer reviewer is relying on the treating physician to provide sufficient clinical information to support the treatment requested.

Additionally, the reviewer must be familiar with a variety of treatment guidelines depending on the jurisdictional requirements. Compound medications present a perfect example of the differences in guidelines. In some states, the guidelines indicate that if any one ingredient is not appropriate the entire compound is inappropriate.   In other states, the reviewer must address each ingredient independent of the others. In some jurisdictions, compound medications may require FDA approval of the ingredients, and given the opioid epidemic, many states are creating independent guidelines to address these requests.

Once the “who” has been identified through the search process then there are a couple of key considerations:

  • Is their medical record clear of malpractice and fraud claims?
  • Are they willing to initiate calls and embrace the true meaning of utilization review by discussing the specifics of the case with the requesting provider? Are they open to a dialogue that may not agree with their thought process or beliefs?
  • Do they follow guidelines in their private practice? If not, it is challenging for them to be able to enforce the guidelines in the review process.
  • Are they committed to reviewing the clinical information personally and to the best of their ability to ensure that not only the current clinical submitted is reviewed but potentially any historical clinical that may be pertinent to the case?
Now you have the candidate – What’s next? Credentialing, of course! Credentialing involves validating state licenses, experience, knowledge, and other factors. Some organizations outsource this process while others perform what is referred to as primary source verification, meaning the organization is responsible for verifying the credentials of the provider.

Another consideration is any malpractice or other blemishes on the candidate’s record. A credentialing committee generally must approve of the candidate, or they may seek additional information from the candidate to explain any items that are discovered via the credentialing process.

At UniMed Direct, we’re committed to finding the best physician reviewers to ensure injured workers receive appropriate care and achieve the best outcomes. In Part 2, we’ll discuss what happens after the credentialing acceptance process.

Karen Atkins

Karen Atkins, Chief Operating Officer with UniMed Direct, is leading the conversation, and the industry, on how to make the utilization review process more efficient for all stakeholders: physicians, insurance companies and, most importantly, patients.