At its Special Meeting of the AMA House of Delegates, the American Medical Association (AMA) recently adopted new policies for peer-to-peer (P2P) review of prior authorization decisions. One new policy calls for the P2P prior authorizations to be made actionable within 24 hours of the discussion. Another calls for the reviewing P2P physician to have clinical expertise to treat the medical condition or disease under review and to have knowledge of the current, evidence-based clinical guidelines and novel treatments.

This second new policy pinpoints the importance of evidence-based medicine, which also is an essential part of peer reviews. Peer reviews utilize a physician-level review – or clinical review – of medical records to determine whether or not to uphold a denial of coverage for a specific claim. They’re used by health plan (payer) professionals to focus on a patient receiving appropriate and medically-necessary services.

What exactly is evidence-based medicine? The American Academy of Family Physicians (AAFP) defines it as the judicious integration of the best available evidence with clinical expertise and an individual patient’s values, preferences and unique circumstances.

In medical reviews such as peer reviews, patient information such as medical records undergo evidence-based clinical review to make sure payment is made only for services meeting specific guidelines and requirements. Doctors conducting these reviews consult the most up-to-date and industry-accepted clinical guidelines, all of which are backed by evidence-based medicine. By promoting transparency, it assists healthcare providers and payers in reducing operating costs and improving productivity and patient satisfaction.

The Peer Review Process

A key goal of peer (clinical) review is to improve the quality and safety of healthcare. It can be a time-consuming process, but it’s important in helping to reduce the cost of healthcare in the United States.

In a peer review, which is performed at the request of a payer, a board-certified physician reviews what steps occurred in the discrete and specific care episode of the patient. He or she then makes a decision as to whether or not the treatment the patient receives is in line with evidence-based and/or plan guidelines.

As we’ve discussed in a previous blog, benefits of peer review include:

  • Increased transparency for payers and providers
  • Improved safety and quality of care
  • Reduced liability through the utilization of external, board-certified specialists in the same or similar field of service as the original provider(s)
  • Decreased risk through proactive risk management
  • Reduced medical errors and adverse events

The Role of IROs in Peer Review

Many payers employ the services of an independent review organization (IRO) for peer reviews. There are a variety of reasons for this. For example, some smaller health plans don’t have enough physician resources to conduct peer reviews. Others want their medical director(s) to focus on other core business objectives.

Either way, IROs offer a way for payers to avoid any potential conflict(s) of interest and receive an unbiased decision on every case. They’re required to adhere to strict compliance requirements, both at the federal and state level. IROs that utilize advanced technology are able to offer their payer clients quick turnaround times, sometimes within hours.

The MLS Advantage

The MLS Group of Companies is a leading URAC-accredited national provider of peer review services. As an IRO, we facilitate treatment recommendations by way of our accredited national network of independent physician reviewers who provide them using evidence-based medicine in their decision-making process. These doctors are active in medical practice and utilize scientifically-sound information, relevant guidelines and plan language in each peer review case.

MLS collaborates with multiple types of healthcare entities, including third-party administrators, insurance carriers, utilization review organizations, hospitals, state and federal agencies and more. Every client has access to our HITRUST CSF-certified platform and portal, and our technology adheres to the guidelines and security standards set forth by URAC. Learn more about MLS and all the services we provide.

Evidence-Based Medicine and IROs in the Peer Review Process