Medical Peer Reviews in Workers Comp. Law

Importance of Medical Peer Review

A Medical Peer review is the process where a second physician (employed by the insurer) reviews the treatment records of the claimant to confirm the medical advice from the first, treating physician was medically necessary. The goal of a peer review is to ensure that any treatment the claimant has received is reasonable for their injury. These are some of the reason you could benefit from conducting a peer review:

• Quality: Maintain quality and costs contained for medical care provided to injured workers.
• Cost Containment: Ensure that medical treatments are appropriate and not overprescribing. A medical peer review is vital to managing costs.
• Fraud Detection: Peer reviews can also weed out red flags or inconsistencies in the medical records. These doctors are also experienced, and can assess the credibility of the documentation.
• Legalities: Make sure your medical treatment aligns with legal requirements, especially if its a case who’s jurisdiction policies you are not familiar with.

Protect the interests of your client by bringing accountability into the claims process.

Benefits for Workers Comp Defense Attorney

Workers comp claims can range from minor back aches to long term, life altering injuries that flood you with medical expenses. Navigating your way through this as a defense attorney requires legal knowledge and some medical background.

You’ve got the experts:

A medical peer review arms you with the expertise of seasoned medical professionals. They scrutinize every aspect of the treatment, ensuring it aligns with the standard of care for your claimants injury.

With these experts at your side, you’re not just an attorney; you’re an attorney armed with a legion of medical minds. Basically the best of both worlds.

You’ve got the resources:

Workers comp claims are a financial battlefield. Keep your client from experiencing excessive medical costs and overutilization of treatments. Doctors are people too and can make mistakes. Getting a second opinion will save you in the long run.

A peer review has your back during instances of fraudulent activity. You have a knowledgeable doctors opinion in your back pocket that you can use during litigation.

For Example:

Your new client is facing a workers’ compensation claim filed by one of their employees, Tracy. Tracy claims to have sustained a back injury while lifting a heavy box during her work duties. She seeks compensation for medical treatment, rehabilitation, and lost wages.

However, your team believes that Tracy’s injury might not be as severe as she claims, and you suspect that she may be exaggerating his symptoms. They are concerned about the potential long-term cost of his claim, which includes ongoing medical treatment and disability benefits.

You, as a great defense attorney, send John’s medical records out for review, which include X-rays, MRI scans, physician reports, and a recommended treatment plan. After selecting an independent board-certified orthopedic specialist with expertise in back injuries you are told that Tracy’s injuries show degenerative changes common for someone her age.

Peer review findings arm you with evidence to question the severity of your claimants injury and the appropriateness of the recommended medical treatment.

Medical Peer Review vs. Utilization Review

Although these two services may seem similar they serve a unique purpose.

Peer Review:

• Aims to ensure medical care aligns with standard of care.
• Focuses on quality and necessity of care.
• Completed by studying the medical records of the patient. The person who does this must hold an MD.

Utilization Review:

• The primary purpose of a UR is to control healthcare costs, prevent overutilization and make sure the system stays affordable.
• Looks at patterns on a broader scale or across a group of patients
• Administrative in nature and is usually done by nurses or someone with enough medical field knowledge. Physician is not required for this.

Bottom Line

In the world of workers’ compensation defense, the need for medical peer review is undeniable. It serves as a safeguard against unnecessary medical expenses, potential fraud, and legal complications. By using this process, defense attorneys can ensure that the right decisions are made, and injured workers receive the appropriate care while protecting the interests of their clients.