Peer review programs can make or break a claims process. A great peer review partner can help ensure that your organization stays up-to-date on technology cycles, legislation changes, and any other important shifts in the healthcare industry. It’s important to look for a Peer Review Program that distinguishes itself through quality work, ongoing training, full compliance, and the latest technology. You want to trust the organization you choose and make sure they are industry certified.

Here are the key elements to look for in a great peer review training program:

Medical Necessity Criteria

• Medical Necessity Criteria (i.e. InterQual, Milliman Care Guidelines (MCG), ASAM, or other criteria) are tools that help you make appropriate treatment determinations.
• Your clinical judgement, experience, and expertise are key factors.
Clinical Rationale:
• The rationale is the most important element of the utilization review as it answers the questions presented
• Peer Reviewers must effectively document their decision making process in order to be successful

Clinical Documentation

• According to NCQA, the following are examples of UNACCEPTABLE clinical rationale language: “The treatment is determined not to be medically necessary.” “The treatment is not a covered benefit.” “The proposed length of stay does not meet our UM criteria.”
• Use your own words! Simply citing patient information is insufficient for an informative utilization review
• It is critical that Medical Directors and Peer Reviewers master documentation of the determination based on clinical rationale.

Understanding Legal Aspects of Peer Review/Medical Director Roles

• Both Peer Reviewers and Medical Directors are subject to a number of regulations.
• There is inherent legal risk with the positon of Medical Director, as well as Peer Review positions both for the individual and the organization.
• A Commitment to Privacy and Confidentiality is critical.

Effective Communication for Healthcare Professionals

• Professionalism and diplomacy should be employed in all communication interactions between reviewers and their peer physicians.
• When listening to the treating physician be an active listener, determinations should be made based on all aspects of a case, including physician input
• Ensure that in leaving messages a call back number is clearly provided as well as information related to the deadline that the case must be closed out by, and the best times to return the call

Inter Rater Reliability, Concordance, and other Key Metrics

  • It is difficult to find concrete indicators to measure IRO/PR performance. The following are some of the metrics that can be utilized to determine the effectiveness of a Peer Review program, and measures which Peer Reviewers and Medical Directors should be appropriately trained on
  • • Results from these performance measurements shed light on ways Peer Reviewers and Independent Review Programs can better support organizations, and where training in the Care Management Departments may need to be implemented

o Turn Around Times (TATs)
o Total number of cases the Care Managers send for Peer Review
o Number of complaints and issue resolution
o Concordance Rates
o Random Case Audits

Download our free white paper to learn how to choose a Peer Review program that values these quality indicators. Each tip has questions that you can ask your prospective peer review partner. If you already have a Peer Review Program, use these tips and questions as a guide. Does your program check all the boxes? If not, it may be time to look for a new vendor.