What Is a Peer Review?
During a peer review, a physician paid by an insurance company reviews and analyzes the medical records written by a patient’s treating physician. This review is conducted so that an insurance company can determine whether services the treating physician rendered to his or her patient were medically necessary.
If the peer review concludes that a certain service was not medically necessary, the insurance company can deny payment of that service. Peer reviews are supposed to be impartial. Nevertheless, because peer reviewers are paid by insurance companies to determine whether a claim should be denied, they are hardly ever that.
What Happens During a Peer Review?
Unlike an independent medical examination (“IME”), a peer review does not entail a medical examination of the patient. The patient does not have to visit the peer reviewer’s office and does not have to submit to any examinations.
What happens is that an insurance company selects a physician of its choice, and pays him or her to review the treatment records of a certain patient. After reviewing these documents, the peer reviewer creates a “Peer Review Report,” and submits it to the insurance company. Usually, the report will contain the peer reviewer’s medical opinions as to whether the services the treating physician rendered were medically necessary to treat the patient’s injuries.
The Law and Peer Reviews
According to Regulation 68, insurance companies are entitled to conduct a peer review as additional verification of a no-fault claim. If the peer review report concludes that the services rendered were not medically necessary (which it will likely do), the insurance company then has a basis to deny the claim based on lack of medical necessity.
However, this does not mean that the medical provider should cease treatment of the patient. If patients continue to experience symptoms, the medical provider should continue treatment. Medical providers should not cease treatment based on a ten-minute review of medical reports conducted by a biased physician.
If the reason for a no-fault claim denial is a negative peer review report, the insurance company must release a copy of that report to the patient, his or her attorney, and/or his or her treating physician upon request of any of these parties.
Claims denied based on peer reviews can be litigated or arbitrated. To establish a viable denial on the grounds of medical necessity, an insurance company must show that the peer review report “set[s] forth a sufficiently detailed factual basis and medical rationale for the claim’s rejection.”
97.5% of denials that are based on peer reviews do not hold up in court or arbitration, and insurance companies are required to pay the treating physician’s claims.
Physician’s Right to Rebut Peer Reviews
Once an insurance company’s physician performs a peer review, the question of medical necessity does not immediately end. A patient’s treating physician can challenge the peer review by writing a rebuttal or by having a third-party physician perform his or her own peer review. Peer review rebuttals raise an issue of fact as to whether services rendered were medically necessary, and thus increase the treating physician’s likelihood of success in litigating the denied claims.
When an insurance company issues a denial based on a peer review, we oppose the denial and use our no-fault expertise to collect on those claims. We have successfully collected on thousands of claims that were denied based on the results of a peer review.
Please note that it is very important for healthcare providers to save all denials based on the results of a peer review sent by insurance companies. Our clients can be sure that all documents from insurance companies, especially denials, are automatically attached to the patient’s billing account within 72 hours of receipt.
Medical providers can rest assured that 97.5% of denials based on peer reviews are not upheld in litigation or arbitration. Here at Tangent, we pride ourselves on exceeding that standard.
 Amaze Medical Supply v. Eagle Ins. Co., 2 Misc.3d 128.