How Peer Review Drives Change Across the Workers’ Compensation System

| | Physician Peer Review


As a key component of utilization review (UR), peer review not only helps ensure patients receive medically necessary care based on evidence-based guidelines, but also benefits doctors, insurance providers, injured workers, and government regulatory bodies. With stronger technology and clinical tools available, data is more robust than ever, helping the insurance and medical industries stay up-to-date on trends in treatment, claims processing, and regulation. When insurance and UR companies keep a vigilant watch on trends, they can react quickly and effectively, adapting to changes and preventing, or at least reducing, troublesome patterns from becoming the norm.

The Many Benefits of Peer Review

What can a peer review uncover? It can identify and track trends at all levels of the industry, proving beneficial in a variety of contexts:

  • Peer review can give us quick insight into quality concerns by tracking the treatments doctors prescribe. Peer review alerts UR organizations and insurance companies to new medications, devices, and techniques emerging in the market. This insight can alert industry stakeholders to explore necessary interventions, especially when patient safety may be at risk, as we are experiencing with the current opioid crisis.
  • Peer review can strengthen business partnerships between UR organizations and their clients. Information sharing uncovers needed process improvements that ultimately lead to cost efficiencies and better healthcare outcomes. For example, peer review creates checks and balances to ensure requested treatment is medically necessary and the least invasive for patients, based on evidence-based guidelines. This ultimately achieves better outcomes than would occur without peer review.
  • Peer review can eventually lead to needed legislative changes. As peer review continues to provide more information about trends in the industry, it helps create a picture of how the industry is responding to government regulations. For example, organizations may identify patient populations that are not returning to work as fast as they should, or they may experience an increase in a particular treatment that may need to have utilization review around it. In this way, peer review can gather the positive or negative reactions of system participants, indicating the need for a change at the legislative level.
  • Peer review drives technological advances. Peer review can detect emerging treatments and process improvement opportunities that lead to better quality of care. Most of these benefits of peer review are made possible because of advances in UR technology. As new developments arise within the industry, UR software must adapt to the changes swiftly and keep UR in compliance. Peer review helps software entities learn when they must update their systems to adapt to upcoming changes. UR software may need to implement new timeframes, notifications and alerts to clients, new audit flags for treatments, and any number of regulatory changes. In the same way that peer review keeps the industry ready for changes, it can help software stay up-to-date as well.

The Bottom Line on Peer Review

For all industry participants, peer review drives necessary change. It allows all parties to take preventative or corrective actions by staying ahead of emerging trends. The industry can bring topics into discussion faster and create the necessary changes before they become widespread problems.

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