There are two primary types of peer review. One is used to manage physician performance and ensure providers’ skills are held to the highest standards. The other is a physician-level review of medical records utilized by health plan professionals to determine whether or not to uphold a denial of coverage for a specific claim. 

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.