The Value of a Peer Review in a Workers’ Compensation Case
When it comes to patient care, expertise matters. No one understands this better than the licensed medical professionals who make decisions that can make the difference between life and death for a patient. Sometimes, a second opinion may be necessary to ensure care quality and patient outcomes align with evidence-based treatment guidelines and current treatment options. In the workers’ compensation claims arena, a medical peer review is utilized to determine whether an injured employee is receiving or being recommended for the appropriate care. A medical peer review can also address whether work injury-related treatment is being provided or recommended in the proper sequence. Workers’ compensation peer reviews are carefully done to examine the services provided based on current jurisdictional requirements and evidence-based medical guidelines.
The benefits of a peer review
While there are several benefits to a peer review in a workers’ compensation case, some of the most notable include1:
- Ensures appropriate treatment for an injured employee, which can help to accelerate recovery time for faster return to work
- Provides an impartial, indisputable, expert medical opinion to stakeholders in a workers’ compensation claim
- Helps mitigate overall claims costs by identifying ineffective (and often costly) medical treatment
The peer review has become an integral part of the workers’ compensation system, especially from a cost-containment and quality assurance perspective. But peer reviews also support injured employees by ensuring they receive the necessary care to recover. And as medical best practices continually evolve, the peer review process helps to keep care providers, employers, and workers’ compensation payors abreast of the evidence-based medical guidelines that should factor into the work injury care decision-making process.
The workers’ compensation peer review process
After an employee is injured on the job and reports the injury to a supervisor, the employer will file a workers’ compensation claim. Then, the employer submits the claim to its payor, which includes a medical report from the treating physician. And based on the course of action determined by the treating physician, requested medical services may be subject to the worker’s compensation utilization review process based on the jurisdiction in which the injury occurred.
“The utilization review process is a two-step process,” said Michael Southwick, Concentra® assistant vice president of Medical Advisory Services and Medical ReviewStream™. “A treating physician requests approval of a treatment plan, which is reviewed by a nurse who applies guidelines administered by the state and determines if services are medically necessary. If the services are necessary, the payor approves treatment; if not, a peer review comes into play.”
The utilization review provider may partner with a peer review service provider to avoid approving treatment that could be considered medically unnecessary or unreasonable. During a peer review, treatment standards are strongly considered. If an irregularity in treatment standards is identified, a peer reviewer may discuss this irregularity with the treating physician. During the peer-to-peer discussion, the treating physician may be able to justify the deviation from the treatment standard. In the end, the peer reviewer will recommend approval, denial, or modification of care to the utilization review provider or agent of record who makes the final determination.
Concentra Medical ReviewStream offers comprehensive peer review services
Peer review of a workers' compensation claim should be conducted by a medical team that understands the evidence-based guidelines and physician specialty match needed to ensure the final review is clinically accurate and adheres to the highest quality standards. Concentra’s Medical ReviewStream is a URAC-accredited organization with a robust quality management program in place to assure clients receive a quality peer review. With a dedicated national medical director, Medical ReviewStream adheres to dependable quality assurance measures that help peer reviewers follow established utilization review standards. The organization builds trust among workers’ compensation payors and employers by offering access to a wealth of relevant services and a level of quality that produces results.
Medical ReviewStream performs daily objective audits of completed complex medical peer reviews and random monthly audits of completed peer reviews and completed appeal reviews. These audits are conducted against a set of standards established by URAC and other industry authorities. Medical ReviewStream consistently earns a quality score in the 98th percentile or higher while receiving recertification from URAC without any deficits from their requirements, confirming its exceptional commitment to high standards. With Medical ReviewStream, employers and payors have the backing of peer reviewers who understand the regulatory side of the utilization review and workers’ compensation processes. And with sophisticated digital technology and information security that tracks and measures the activity of a work injury claim from intake to completion, peer reviewers can help streamline the workers’ compensation claims process.
“Our solutions are tightly integrated with claims systems to relieve examiners of expensive, time-consuming, tedious work, enabling them to concentrate on delivering effective and cost-efficient managed care,” explained Southwick.
Ultimately, timely peer review decisions can be made, meaning employees can receive the necessary treatment promptly for faster recovery and return to work, and work injury claims can be closed sooner. From serving as a sounding board that objectively addresses clinical questions to mitigating the costs associated with recruiting, training, and quality-checking individual peer reviewers, Medical ReviewStream helps remove the administrative and regulatory challenges often associated with workers’ compensation peer reviews while directing the focus back on patient care and improved outcomes.
Expertise and scope of service influence the peer review process
Successfully navigating the medical review process of a workers’ compensation claim means validating the appropriate care promptly for the best possible outcomes. But the quality of a peer review depends on the level of expertise and scope of service provided by the medical reviewer. Medical ReviewStream can serve as a single source during the workers’ compensation claims process for employers and payors in need of initial peer reviews and reconsiderations/appeals.
- Bean, M., Erdil, M., Blink, R., McKinney, D., and Seidner, A. (2020). Utilization review in workers’ compensation. Journal of Occupational and Environmental Medicine, 62(6).