According to the Society of Physician Entrepreneurs, i.e., SOPE, an entrepreneur is someone in the ‘pursuit of opportunity with scarce, uncontrolled resources’. According to them, all entrepreneurs have a goal, i.e., using innovation to gain an end goal. Considering that physicians could be regarded as small to medium-sized business owners, they are also social entrepreneurs, intrapreneurs, and, finally, technopreneurs due to their constant use of new technologies. Because of the vast role fulfilled by doctors, many use their education to benefit the healthcare field.

How Doctors Can Use Their Training

Doctors can use their extensive yet intensive training outside a clinic situation in several ways. We will look at a few of these.

In Healthcare Technology

Doctors, due to their direct involvement in taking care of patients, make a good choice as startup leaders when the focus is on the development of healthcare technology. This is largely because they know and understand the products and services needed to meet the workflow needs of healthcare providers, as well as industry regulatory standards.

Interestingly, the American Medical Association, i.e., AMA, launched an online community connecting and matching doctors with companies in the digital healthcare field as well as entrepreneurs. the initiative, launched in 2017, is known as the Physician Innovative Network (IN). One of the industry’s main focuses is healthcare spending containment. Using new technology may help in this regard.

In Management Consulting

Doctors involved in tech and other healthcare initiatives can use their medical expertise and experience to analyze processes and strategies, and, often, make them better. An example of this is staffing budgets within a healthcare facility. They could recommend the best way of using resources already in place without having to spend more money. They could also look at safety and security guidelines and suggest ways to improve them to better secure a patient’s personal information. This would not only protect a patient’s personal information but help reduce an institution’s litigation risks in the process.

As Independent Medical Reviewers

As an independent medical reviewer, a doctor, by examining a patient’s chart, and employing evidence-based research, and taking industry guidelines into account, assesses whether another doctor is giving the patient the correct treatment. CPRO, for example, is one of the independent review organizations these independent medical reviewers belong to so as to execute this type of work.

Essentially, as a practicing physician reviewer ensures the integrity and credibility of the medical profession.

This review process, however, means that physicians should constantly ensure they are on track with the latest medical research and developments. This is important in not only their personal and review work but also to ensure that any claims appeals are dealt with fairly and objectively.

Employing Their Skills For The Better Good

Studying to become a doctor takes years of hard work. During this time, physicians not only hone their skills but utilize their knowledge to help others. Approximately a third of physicians have alternative income streams besides their practice. Whether they help in the invention of technology solutions or help identify potential problems in a patient’s treatment and suggest ways to rectify the situation, they have many options to use their knowledge outside of only seeing their own patients. By seeking other avenues of employment, a doctor can improve his skills, further his education, or even give medical training to others. The options are almost limitless.

CPRO offers physicians the opportunity to become independent medical reviewers.  To apply to be an independent medical reviewer for CPRO, email your resume to manager@caribbeanpeerreview.com

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The Third-Party Administrator

A TPA refers to an independent organization that handles and processes all medical insurance claims. This they need to do following a set of drawn up laws. Very often, when an insurance company finds themselves unable to expedite a claim, they will work with a TPA to do so. Although the TPA may handle the claim, the paying of the claim is in the hands of the insurance company or self-insured employer.

How The Third-Party Administrator And Independent Review Organization Collaborate

When you, as an employee, submit a workers’ compensation claim, you would usually have to undergo an insurance medical examination. This examination would check on the severity and breadth of your injury. A TPA, in assessing the claim, would usually partner with an independent medical review organization that would carry out the medical view process. These organizations have a network of qualified physician reviewers who work at assessing workers’ compensation claims.

Why The Need For An Independent Medical Examination?

If you are injured while at work, a doctor does a medical examination to find out what kind of treatment to administer. An insurance company may, however, need more information about your injury. In some cases, they may even dispute your doctor’s conclusion about your medical injury or its extent. They would thus ask for an independent medical exam. These exams are done by qualified, practicing physicians who give an unbiased medical opinion.

The Importance of Peer-To-Peer Reviews

Part of the workers’ compensation review process sees a specialty-matched physician taking a close look at your case. He will assess the nature and proposed treatment of your injury. These reviews often help in stopping the need for unnecessary, expensive treatments if found not necessary. In so doing, a healthcare body can rather use the money saved in bettering safety standards as well as focusing on the development of preventive health initiatives. A peer review can thus help with claims management as it helps determine impairment ratings and whether you, as an employee, can return to your work. An IRO thus helps speed up the process of getting an employee back to work.

In Conclusion

A third-party administrator when partnering with an independent review organization may help expedite claims and help an employee return to work faster. This smooths the process and helps both employees and employers.

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• Peer reviews of journals to ensure any scientific paper is scrutinized by an expert peer in their field.
• To ensure a doctor’s skills and performance are of a high standard.
• The review of medical records helps determine whether a claim is covered or not.

In all instances, these reviews are undertaken by a healthcare expert in the same area of expertise as determined by a specific medical claim.

An example of this is where, if a claim were the result of a test or procedure carried out by a heart specialist, someone of equal standing would review that particular case. This is known as a specialist-to specialist review.

What Happens During a Peer Review?

Each peer review, undertaken by a medical professional of equal or higher standing, looks at both the patient and his clinical condition. The physician undertaking the review would look at the steps taken in the treatment of the patient. This type of review is usually requested by either a health plan or an insurance company. The reason for this is that these entities do not have permanent staff that can deal with these issues. This is especially the case when a rare medical situation is involved. At times, a health plan or insurance company may ask an independent review organization for help, whereby they, in turn, would turn to one of their specialists and sub-specialists forming part of their network.

Why Health Plans Ask For Medical Reviews

Smaller or mid-sized health plans usually only employ up to three doctors permanently. These doctors are usually general practitioners. When presented with a case outside their area of expertise, they may ask an independent review organization, which has a specialist in that field, to review it. They may also have a conflict of interest and, by enlisting outside help, circumvent the issue.

Compliance is another reason they may ask for an independent medical review. Workers’ compensation cases are a good example. Here, the legislation that governs reviews may specifically state that the peer review must be done by someone with the same specialty. As smaller health plans do not have a wide range of specialists on their staff, an independent review organization may be called in to do so.

The Appropriate Care

Peer reviews focus on ensuring that a patient receives the appropriate and necessary medical care. Doctors keep up to date with the newest clinical guidelines that are backed by evidence-based medicine. In so doing, they ensure accurate peer reviews. It also allows for a streamlined review process by licensed reviewers from third-party vendors. This benefits the healthcare industry in general because it improves productivity and secures patients’ rights.

Amongst the physician level review benefits we can include the following:

• An improvement in the quality and safety of care provided
• A partnership with an independent review organization
• A reduction in the number of medical mistakes
• An increase in transparency at all levels
• An unbiased, evidence-based outcome
• A decrease in risk due to proactive risk management
• Liability reduction due to the employment of certified specialists in the same field as the original physician

The independent review process sees a reviewing doctor examining a case as handled by the original physician. He may speak to this physician to find out whether any information is lacking in his notes. Sometimes certain documents may be amiss or difficult to understand. This, therefore, aids the communication process so that the reviewer may get the necessary information needed to form a conclusion. The physician belonging to the independent review organization doing the peer review has the ability and resources to ensure a quick turnaround time that meets state or federal guidelines and their recommendations. The feedback is unbiased and thus eliminates any conflict of interest. It also ensures that both parties get treated fairly.

By investing in an independent research organization with a wide variety of skilled medical professionals, you gain immediate access to their services. These professionals, each a skilled leader in their field, each has their own practice and stay on top of all the latest medical developments.

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Defining An Independent Medical Review Company

An independent medical review company is also called either an independent review organization or a peer review company. An independent review company does medical assessments. They are objective in their conclusions and work independently from any medical insurance company. Usually, you would request an independent medical review after exhausting an appeal process via your medical insurance provider.

Challenges Posed By A Workers’ Compensation Claim

Most of the challenges faced by those involving workers’ compensation claims are the same. Amongst these challenges you may find the following:

1. An increase in the complexity of submitted claims
2. An increase in healthcare and medication costs
3. The health and lifestyle of an employee, i.e., diabetes, joint pain, obesity, etc.
4. Changes in laws and regulations at a local and national level
5. Data safety breaches
6. Driving while distracted
7. The rise in drug dependency
8. An accumulation of trauma due to previous injuries or overuse of certain healthcare provisions or medications
9. Mental health issues and the rise in post-traumatic stress disorders as found in police officers and other frontline workers

A professional medical review company would pride themselves on their experience and competency in handling these complicated issues while helping clients navigate the claims process. The involvement of qualified medical staff, administrators, and peer reviewers helps expedite the process.

How An Independent Medical Review Company Helps Both Employee And Employer

If you sustain an injury in your workplace, you may need to start a workers’ compensation claim. This could be a confusing, frustrating procedure. As an employee, you want to make sure your employer covers your medical expenses. As an employer, you want to make sure that any medical treatment given to an employee is pertinent to the injury and considered necessary and compliant with governing laws and regulations.

An independent medical review company uses the services of physician reviewers that give an unbiased view based on the evidence received. This allows for a streamlined review process, as each physician used is matched with the case at hand. Each an expert in their field, these experts use their expertise in ensuring a patient receives the correct treatment to return to work.

The post Dealing With Workers’ Compensation appeared first on Caribbean Peer Review.

Utilizing Physician Peer Review

Peer review is used by hospitals and other health care facilities in a variety of ways. Some hospitals are required to use peer reviews for existing doctors to maintain their privileges, and for new physicians seeking privileges at the facility, according to an article by Dinesh Vyas and Ahmed Hozain from Michigan State University and published in the World Journal of Gastroenterology. Hospitals, doctors and administrators can request peer reviews of their colleagues if they are concerned about the quality of patient care. Additionally, facilities use peer review of random or selected patient’s charts to identify problem areas and improve quality of care. While this last reason appears most directly related to patient care, all peer review benefits patients by ensuring physicians are highly qualified in their areas of practice and treat all of their patients within the standard of care.

An Exchange of Ideas

Peer review often occurs through internal or external peer review committees. These committees include physicians with varying backgrounds and disciplines, bringing a variety of knowledge to the table. They generally review other physician’s charts to determine if patient care met the relevant standard of care. The physicians use discussion and an open exchange of ideas to evaluate the other doctors’ work, enabling everyone involved to better understand the various options and roads they can take with patients while maintaining the standard of care and providing the best medical care possible.

Identifies Strengths and Weaknesses

Peer review enables doctors to learn where they lack knowledge, how they need to improve and where they excel. Internal or external peer review of a physician’s performance offers constructive feedback intended to make him or her a better doctor.

This knowledge can also help facilities shift where patients are assigned for certain types of care. By identifying physicians’ strengths and weaknesses, facilities can send patients to the most knowledgeable doctor or transfer a patient to a new doctor when more is known about the patient’s condition.

Directly Related to Quality of Patient Care

Hospitals and other facilities have many tools to measure patient care and promote the highest standard of care possible. Peer review is one of these tools.

Quality care for patients relies on knowledgeable doctors who care for patients to the best of their abilities and purposefully maintain the relevant standard of care; the peer review process identifies those physicians who do not. This process can lead to the dismissal of poorly performing or unethical physicians who don’t improve their work. It can also lead to additional training for less experienced doctors who want to improve. Whether physicians are removed from treating patients or improve their performance, peer review protects patients and promotes providing the highest quality of care possible.

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•  Clinical and intellectual stimulation: Applying current, evidence-based medicine to case reviews is interesting and professionally satisfying.
•  Self-improvement and awareness: Reviewing cases helps physicians improve their own clinical care and documentation.
•  An opportunity to make a difference: Serving as an objective external case reviewer offers a way to improve care provided by others and give back to the medical community.

The post Why become an external peer reviewer appeared first on Caribbean Peer Review.

The main goals of peer review are to improve the quality and safety of patient care, reduce an organization’s malpractice liability and meet regulatory requirements. These include accreditation, licensure, and insurance participation. Physicians consult the most up-to-date and industry accepted clinical guidelines, backed by evidence-based medicine, to ensure their reviews are accurate.  

IMR: Benefits of an experienced resource 

For independent medical review (IMR) or medical case review, healthcare providers may opt for an external peer review company when they lack the appropriate internal resources, such as employees, time, and specialty knowledge.  

 Peer review companies, also called independent review organizations, have the technology and diverse physician networks to deliver quicker turnaround times, provide unbiased decisions, and eliminate conflicts of interest to ensure medical peer reviews accurately determine the appropriateness and necessity of patient care. For health plans, peer review companies have been found to have a positive influence on health plans’ internal review processes, such as accelerating time frames for review and bringing in more external specialists for reviews of complex cases. 

According to the National Association of Independent Review Organizations (NAIRO), advantages of employing the services of a peer review company include: 

• Reduced liability through the utilization of external, Certified Specialists in the same or similar field of service as the original provider(s). 
• Reduced liability through the development of standardized medical criteria for prior authorization. 
• Improved member satisfaction through provision of an unbiased, evidenced-based external determination. 

• Ensured compliance with state and federal mandates for appeals and medical necessity denials. 

The technology effect 

Advances in healthcare technology have improved the quality and speed of the peer review process. Peer review companies, such as CPRO, manage independent medical reviews through highly secure and intuitive client and reviewer portals. These can decrease turnaround times, ensure HIPAA-compliant communication and provide greater accessibility to a comprehensive panel of actively-practicing, reviewers in multiple specialties and subspecialties. 

 Additional merits of technology integration in the peer review process include: 

• Capability for remote peer review by active-practicing physicians 
• Completion of more peer reviews in less time 
• Easier access to up-to-date information on federal and state regulations 
• Identification of gaps in documentation 

• Reduced conflicts of interest 
• Comprehensive data reports for trend analysis 
• Improved transparency 
• Quicker feedback and quality assurance process 

 Technology will almost certainly continue to change and shape the peer review process.

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