Why Take Risks?
According to a study conducted by the Mayo Clinic and published in 2017 by the Journal of Evaluation in Clinical Practice, 20 percent of all first diagnoses are incorrect, and a large percentage of the rest are incomplete.
In other words, getting your case reviewed by a qualified, objective peer can be good for both the patient and your practice or business. That outside voice can be essential in discovering health care fraud and abuse; can supply a confirming opinion or shed light on a misdiagnosis; can show an overlap in a dissenting view and open up an area of discussion; and can facilitate claims resolution and settlement or, if performed in advance, on the side of caution, can even prevent that process from needing to occur.
Cases can undergo peer review at various points; in general, the earlier they occur, the better it is for both the patient and the practice or business, as effective and efficient treatment depends upon the accuracy of the diagnosis. You can have a peer review a current case, or review one that is in medical or legal difficulty.
What is generally required for an accurate peer review to take place are all medical records, including the results of X-rays, MRIs, CTs, or other scans and lab tests that have been performed; all charts; all prescriptions; and, in the case where nursing home visits or home health care supervision occur, the documentation showing the reasons and the frequency. If it is a situation where an insurance claim has been denied, the billing and coding documentation are necessary as well. Paper-based evaluations can be done; the patient does not necessarily need to be re-examined. In some cases, if reviews of radiology results come to a different conclusion, these tests may need to be re-administered; make sure that the source you are using for the peer review has this capability.
A peer review can help clarify a causal relationship from an injury on someone’s property or at the workplace. It will present an expert point of view on a treatment plan that has been prescribed or followed; about compliance with Medicare or Medicaid standards; about the appropriateness of care; and about the medical necessity of that care. It’s important that the review be performed by someone outside your own institutional culture, because physicians in the same practice, hospital, and even insurance companies generally adhere to similar ways of diagnosing and treating; you want someone who brings a different viewpoint and a different philosophy so that you are not merely duplicating the effort.
For your own protection, a peer review should be added to your paradigm for care.