Peer review companies: Contributing to healthcare quality

Doctors have transformed modern healthcare in the United States for many years. Sir William Osler, one of the four founding professors of Johns Hopkins Hospital, is often referred to as the Father of Modern Medicine. Elizabeth Blackwell became the first female doctor in the U.S., and James McCune Smith was the first African-American to hold a medical degree. The first Native American physician in this country was La Flesche Picotte. 

Each of these noteworthy physicians has helped to shape healthcare in the U.S. Our current healthcare system depends on a system of peer review, for everything from clinical performance to medical research to insurance claims, which ensures the medical community is delivering appropriate and evidence-backed treatments. There are two primary types of peer review. One is used to manage physician performance and ensure providers’ skills are held to the highest standards. The other is a physician-level review of medical records utilized by health plan professionals to determine whether or not to uphold a denial of coverage for a specific claim. 

The main goals of peer review are to improve the quality and safety of patient care, reduce an organization's malpractice liability and meet regulatory requirements. These include accreditation, licensure, and Medicare participation. Physicians consult the most up-to-date and industry accepted clinical guidelines, backed by evidence-based medicine, to ensure their reviews are accurate.  

A history of clinical peer review 

The clinical peer review process was established more than 100 years ago to monitor physician behavior and define minimum standard of care requirements for hospitals and their medical staff. This changed in 1952 when the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which is now called the Joint Commission, started requiring all U.S. hospitals to employ clinical peer review for physician performance.  

Upon the emergence of obstacles to fair peer review, Congress put into law the Health Care Quality Improvement Act (HCQIA) in 1986. One of these challenges was physicians facing possible negative consequences if what they discussed during a peer review reflected badly upon the institution by which they were employed. It promotes confidentiality in the process and gives immunity to panel members who participate in it. 

Congress provided the following reasons for enacting HCQIA: 

• The increasing occurrence of medical malpractice and the need to improve the quality of medical care have become nationwide problems that warrant greater efforts than those that can be undertaken by any individual state. 

• There is a national need to restrict physicians from moving from State to State without disclosure or discovery of their previous damaging or incompetent performance. 
• This nationwide problem can be remedied through effective professional peer review. 
• The threat of private money damage liability under Federal laws, including treble damage liability under Federal antitrust law, unreasonably discourages physicians from participating in effective professional peer review. 
• There is an overriding national need to provide incentive and protection for physicians engaging in effective professional peer review. 

IMR: Benefits of an experienced resource 

For another type of peer review, referred to as independent medical review (IMR) or medical case review, healthcare providers may opt for an external peer review company when they lack the appropriate internal resources, such as employees, time, and specialty knowledge.  

Peer review companies, also called independent review organizations, have the technology and diverse physician networks to deliver quicker turnaround times, meet the appropriate state and federal guidelines and recommendations, provide unbiased decisions, and eliminate conflicts of interest to ensure medical peer reviews accurately determine the appropriateness and necessity of patient care. For health plans, peer review companies have been found to have a positive influence on health plans’ internal review processes, such as accelerating time frames for review and bringing in more external specialists for reviews of complex cases. 

According to the National Association of Independent Review Organizations (NAIRO), advantages of employing the services of a peer review company include: 

• Reduced liability through the utilization of external, Board Certified Specialists in the same or similar field of service as the original provider(s). 
• Reduced liability through the development of standardized medical criteria for prior authorization. 
• Improved member satisfaction through provision of an unbiased, evidenced-based external determination. 
• Ensured compliance with DOL/ERISA compliance guidelines. 

• Ensured compliance with state and federal mandates for appeals and medical necessity denials. 

The technology effect 

Advances in healthcare technology have improved the quality and speed of the peer review process. Peer review companies, such as MLS Group of Companies, manage independent medical reviews through highly secure and intuitive client and reviewer portals. These can decrease turnaround times, ensure HIPAA-compliant communication and provide greater accessibility to a comprehensive panel of actively-practicing, board-certified reviewers in multiple specialties and subspecialties. 

Additional merits of technology integration in the peer review process include: 

• Capability for remote peer review by active-practicing physicians 
• Completion of more peer reviews in less time 
• Easier access to up-to-date information on federal and state regulations 
• Identification of gaps in documentation 

• Reduced conflicts of interest 
• Comprehensive data reports for trend analysis 
• Improved transparency 
• Quicker feedback and quality assurance process 

Technology will almost certainly continue to change and shape the peer review process. As Jacqueline Martin, National Sales Executive at MLS, explains, “Being able to replace many of the manual processes has been a great advantage for MLS and our clients. The technologies we utilize enable us to offer clients quicker results without affecting the quality of services we provide them. Plus, we have greater access to myriad resources that allow us to identify updated medical guidelines and resources, as well as state and federal regulations. As new client needs emerge, we are able customize our portal and ensure the same quality standards are in place.” 

Learn more about the MLS Group of Companies and how we demonstrate our commitment to maintaining the highest standards for healthcare cybersecurity.