Why Risk Management is Critical to Physician Peer Review

| | Physician Peer Review

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Risk Management
In utilization review (UR), certain treatments may be subject to physician peer review to determine medical necessity. The result is a report that provides the clinical rationale and evidence to support the determination made by the physician peer reviewer. To prevail in appeals and in court, peer review decisions must be evidence-based, credible and fully explained in accordance with applicable regulations. A decision to deny, modify or approve treatment can have an impact, positive or negative, on a patient’s recovery, return-to-work and overall quality of care; therefore, managing the risks associated with peer review is crucial.

Start with Quality Peer Review Physicians

UR providers must carefully review the qualifications, credentials and competency of physicians who apply to handle peer reviews. Peer reviewers should also be knowledgeable of current trends and changes in the healthcare industry. Physicians who retired from active practice 20 years ago, for example, may not be a good fit, as they may not be aware of new evidence and treatments.

When considering hiring peer review doctors, UR providers should conduct background checks through the National Practitioner Data Bank (NPDB). Doing so alerts UR providers to past misconduct or malpractice issues. NPDB enrollees receive continuous 24/7 monitoring for any new adverse actions and real time updates. Waiting for a physician to notify a UR operation of a problem may create unnecessary risk. When encountering a physician with an adverse action, it is good practice to request a written statement from the doctor explaining what happened.

A negative action doesn’t always disqualify a physician from performing good peer reviews but the UR company’s Medical Director should participate in the investigation to ensure the physician is a fit for the organization. In addition, state licenses and board certifications should be validated to verify they are current and have no restrictions. This should be done only through a primary source verification site; accepting a copy of a license or board certification is not sufficient. After verifications, UR providers must continue to monitor peer review physicians for any adverse actions license or board certification expirations, and up-to-date contact information, active practice hours, and other documentation.

After credentialing, new peer reviewers should undergo training to ensure they understand their performance expectations, the quality standards around the review process and how to fully utilize any software or resources available to them. Open and frequent communication about the UR process, their performance, and the tools utilized to support that process is vital to a successful partnership.

Ensure High Quality, Accurate and Compliant Reports

UR providers must carefully monitor the reports peer reviewers generate. The reports must be defensible. If a case goes to appeal or court, clients must have the necessary rationale to defend the physician’s decision.

A strong UR risk management program starts at the front line. The program should include quality checking peer review reports prior to reports going out the door. This type of quality assurance involves not only looking at the appropriateness of decisions but also carefully scrutinizing the evidence cited by the doctors in making the decision. Did the peer review doctor use evidence-based guidelines? Does the respective state of jurisdiction mandate specific guidelines? Are the peer reviewers making independent decisions and disregarding evidence? The UR provider’s risk management program is responsible for checking that physicians are using sound evidence-based guidelines and not relying on consensus.

UR providers must also ensure that reports comply with regulatory and/or accreditation requirements. Some states mandate certain evidence or language in reports or require a physician to make peer-to-peer contact attempts with requesting providers prior to issuing a determination. In contrast, an ex parte state may prohibit contact with the requesting provider.

A strong risk management program must have processes in place to ensure physician reviewers understand these requirements and expectations. The program should also measure and document compliance with quality standards and any regulatory or accreditation requirements.

Ultimately, risk management helps UR providers ensure their peer review process is sound. Physician reviewers must be qualified and unbiased, they must use evidence-based guidelines to make strong, defensible decisions, and their reports must be thoroughly vetted before leaving the organization. With a strong risk management system in place around physician reviewers, UR companies can minimize risk while ensuring patients receive the best treatment and most favorable outcomes.