Physician Reviewer in Healthcare: Unveiling the Truth

Physician reviewers are medical professionals who evaluate the quality and appropriateness of healthcare services and treatments. They play a vital role in ensuring that patients receive the best possible care and outcomes, while also reducing unnecessary costs and risks. In this blog post, we will explore the role of a physician reviewer in healthcare, how they are trained and certified, and what challenges and opportunities they face in the current and future landscape of healthcare.

What is a Physician Reviewer?

A physician reviewer is a licensed physician who has completed additional training and certification in a specific area of expertise, such as utilization management, quality improvement, or medical necessity review. A physician reviewer works for a health plan, a hospital, an independent review organization, or a government agency to review medical records, claims, appeals, and other documents related to health care services and treatments. The purpose of their review is to determine whether the services and treatments are medically necessary, appropriate, effective, safe, and compliant with the established standards and guidelines.

A physician reviewer may perform different types of reviews depending on the context and scope of their work. Some common types of reviews are:

• Pre-service review: A review that occurs before a service or treatment is provided to a patient. The physician reviewer evaluates the proposed service or treatment based on the patient’s condition, medical history, and evidence-based criteria. The physician reviewer may approve, deny, or modify the request based on their findings.
• Concurrent review: A review that occurs during the course of a service or treatment. The physician reviewer monitors the patient’s progress and response to the service or treatment and may adjust the authorization or duration of the service or treatment as needed.
• Retrospective review: A review that occurs after a service or treatment has been provided to a patient. The physician reviewer assesses the outcomes and quality of the service or treatment and may identify any issues or discrepancies that occurred during the process. The physician reviewer may also provide feedback and recommendations for improvement to the providers and health plans involved.

How is a Physician Reviewer Trained and Certified?

A physician reviewer must have a valid medical license in the state where they practice. They must also have at least five years of clinical experience in their specialty area. Additionally, they must complete a formal training program that covers topics such as:

• The principles and practices of utilization management, quality improvement, and medical necessity review
• The standards and guidelines for evaluating health care services and treatments
• The legal and ethical aspects of health care review
• The communication and documentation skills for health care review
• The use of technology and software for health care review

After completing the training program, a physician reviewer must pass an examination that tests their knowledge and skills in health care review. The examination is administered by a recognized accrediting body, such as the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) or the American Board of Medical Management (ABMM). A physician reviewer must maintain their certification by completing continuing education courses and renewing their examination every few years.

Challenges and Opportunities for a Physician Reviewer?

• Enhancing their professional development and expertise in health care review
• Expanding their network and collaboration with other health care professionals
• Participating in research and innovation in health care review
• Attending conferences and events related to health care review, such as AMCP

AMCP

AMCP is an annual meeting (March) organized by the Academy of Managed Care Pharmacy (AMCP), which is the leading professional association for managed care pharmacy. AMCP will bring together thousands of pharmacists, physicians, nurses, researchers, administrators, policymakers, and other stakeholders to share best practices, insights, and innovations in managed care pharmacy. AMCP 2023 will also feature keynote speakers, educational sessions, poster presentations, networking events, exhibits, awards, and more.

One of the highlights of AMCP 2023 will be the Physician Reviewer Forum (PRF), which is a special session dedicated to physician reviewers. The PRF will provide an opportunity for physician reviewers to learn from experts, exchange ideas, discuss challenges, and explore solutions in health care review. The PRF will also cover topics such as:

• The latest trends and developments in health care review
• The impact of COVID-19 and other emerging issues on health care review
• The best practices and tools for health care review
• The collaboration and integration of physician reviewers with other health care professionals
• The career advancement and recognition of physician reviewers

The PRF will be a valuable and rewarding experience for physician reviewers who want to enhance their knowledge, skills, and network in health care review. The PRF will also help physician reviewers prepare for future challenges and opportunities in health care review.

Where To Go From Here

Physician reviewers are essential members of the health care team who ensure that patients receive the best possible care and outcomes while also reducing unnecessary costs and risks. They are trained and certified in specific areas of expertise and perform various types of reviews to evaluate the quality and appropriateness of healthcare services and treatments.

Physician reviewers face challenges in keeping up with changing standards, balancing clinical judgment and evidence-based criteria, and managing complex cases. However, they also have opportunities to contribute to improving healthcare quality, enhance their professional development, collaborate with other healthcare professionals, and participate in research and innovation.

Attending conferences like AMCP and engaging in events like the Physician Reviewer Forum can be beneficial for physician reviewers to stay updated, exchange knowledge, and explore solutions. By actively participating in these opportunities, physician reviewers can continue to play a significant role in shaping the future of health care review and improving patient outcomes.

References:

• American Board of Quality Assurance and Utilization Review Physicians (ABQAURP)
• American Board of Medical Management (ABMM)
• Healthwise Staff. (2019). Utilization Management: What You Need to Know.
• (n.d.). Independent Review Organization Accreditation.