By Nicole Bednarek and Jim Bobeck
Why would an IRO bring an attorney into the peer review mix? The reason is pretty simple: Physicians write wonderful decisions as determined by the medical evidence of case, but attorneys make sure they stick to the issue at hand and don’t venture into unnecessary dicta, which can invite claims of libel, negligence, and breach of contract.
While your group may not use an attorney or incorporate a legal review, there are four critical tips that all medical reviewers can use to keep you safer and focused in your reviews.
- Remain conflict-free. This tip is the most important. Take a look at the parties involved, directly and indirectly. Do you have a relationship with them financially or professionally? Is there compelling reason that would hamper your ability to provide an impartial determination? Conflict-free doesn’t mean recusing yourself just because someone may think there’s a potential conflict, particularly if the potential conflict is far-fetched. Instead, one should ask whether a reasonable person would determine that your relationship with the parties involved impacts your impartiality. If in doubt, feel free to pass on the case.
- Stay in your (issue) lane. Focus on the question asked of the medical reviewer, not the questions you think should have been asked. Because physicians or other medical reviewers (pharmacist, CRNP, RN) can readily understand a case and determine the type of care that should be provided, they can lose focus of the actual service in question. A reviewer may think that the beneficiary should have asked for a different prescription than the one in question, but the actual request limits the scope of the reviewer’s purview.
- Read the member handbook. For anyone who has reviewed a Medicaid case, medical necessity often has a far more stringent definition than it would in a commercial health plan. Less services are routinely covered by particular health plans, but the member handbook determines the scope of benefits in many cases. When reviewing cases, a physician will often know exactly what type of care should be provided, but it does not mean the health plan necessarily includes those benefits or services. Stick to the handbook, as the handbook provides the denial basis.
- Do not disparage a fellow practitioner. When reviewing cases, the conduct of the requesting physician can insult the senses of the external peer reviewer. The reviewer may wish to point out the quality care issues committed. While a reviewer may feel justified for the sake of good medical care, those concerns are not within the scope of the actual peer review case. Such comments can lead to negligence and open one to liability via libel.
In summary, be careful out there. If you cannot have legal review of cases prior to issuance, heed the aforementioned tips. For 15 years, FHAS has always involved an attorney in our physician peer review process to review reports and recommendations prior to issuance. Cases are still cost-effective and better in the end for all parties involved.