Dr. Skip's Medical Peer Review Blog: Optimizing Your Request for Medical or Peer Reviews

Thursday, September 14, 2006

Optimizing Your Request for Medical or Peer Reviews

If you're a claims manager, utilization management nurse or case manager and you're sending cases to an Independent Review Organization for medical peer review, here are some important tips that can make your next review easier and maybe cost less.

1. Your request should clearly state exactly the issues that you want us to review about your case. Point out the defining issues which are most important to consider.

2. Ask clear questions that get to the heart of the matter or the issue that you're trying to get a determination about. From time to time, clients send us vague questions or ask redundant or extraneous questions that don't get to the heart of the matter. Framing your questions properly is very important when you're requesting an independent medical review.

3. Don’t overstate the number of questions you want answered, because the cost of an independent medical review is directly a function of the number of questions that you want us to review. The cost of course is also driven by the number of pages that we're requested to review. When we look at thousand pages on a case, obviously it's going to cost a lot more than hundred pages.

4. Another way that you can reduce the cost of your medical reviews is to make sure that you only send us the pages that are really relevant to your questions. Of course we don’t want our clients to skim through and eliminate pages that could provide good background information on the case. On the other hand, it does make sense to eliminate any extraneous internal communications that are not germane to the case before they're prepared and sent to us.

If you are considering sending cases into an Independent Review Organization for medical review, make sure that you frame your questions properly and succinctly and that you reduce the questions to the ones that are most important to rendering a determination.

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