Jim: Hi, I’m Jim Mangraviti. I’m with Steve Babitsky. We’re both from SEAK, Inc. And we’re here today to talk about how to write a medical file review, peer review, however you want to call it. Steve, what is a medical file review or a peer review?
Steve: It’s a review requested by insurance companies, IROs, and other companies in which a physician hired on a contract basis review medical records to answer questions by the client. It may be about utilization review, it may be about reasonable and necessary treatment. It may be about other issues similar to that. So it’s the kind of thing where it’s done on a paper review. There’s no physician-patient relationship. The client sends you electronically a question, send you the records, ask you to answer certain questions and you answer those questions and send it back to them.
Jim: Now, why is it really important that a peer review or a file review be well written by the doctor?
Steve: Well, the client has certain questions they need answered. So for example, if somebody is going in for treatment, they might be trying to get a knee replacement, they may need a kidney replacement or something like that, they’re going to a hospital, and the question becomes whether or not the insurance company is going to be responsible for this. That could run $30,000, $50,000, hundreds of thousands of dollars. So the question they will send you is, “Here are these medical records. Does this person qualify under the contract to get this kind of treatment?” So it can be extremely important, and it could be a lot of money involved and it also could affect the welfare and well-being of the patients.
Jim: Can you give our viewers an idea of what a well-written peer review looks like?
Steve: Well, first and foremost, you want to answer the questions that are asked by the client. And generally speaking, you want to list the questions, and then underneath the questions list the answers. Now, it’s not only the answers. You also have to give the client your rationale or your discussion, your analysis about how you got to the answer. So if they ask you, for example, does this patient qualify for Botox treatment under the contract, you have to know that they need a certain amount of treatments and a certain amount of unsuccessful treatments before they can get the Botox treatment. In addition, you will need to know the contractual language. So if they need to have so many migraine headaches a year, then you have to put that in your analysis. So these are the kinds of things that are important.
Jim: Could you maybe go over three mistakes that you commonly see in docs when they’re writing peer reviews?
Steve: Sure. The first thing is that they don’t answer all the questions asked. So they’ll ask five questions and only answer four. And that creates a big problem because then the client will have to send the report back and ask them to answer that question. Sometimes the doctors answer questions that are not in the request. So they might ask you about disability and the doctor gets into causal relationship. And sometimes they go off on tangents that are not relevant to the case and can create problems. So for example, if they’re asked as to whether or not a person has an orthopedic disability, the doctor may say no, but then put in there something about a psychiatric overlay, which can create a significant amount of problems for the client and actually cost them a lot of money.
Jim: Well, what resources does SEAK offer for doctors that are either doing file reviews or want to get into this work?
Steve: We have two main resources. The first is a course that we have, How to Start, Build, and Run a Successful Disability and File Review Practice. That’s an excellent two-day course. I teach that with two physicians who are very well experienced in doing this work. They work for major insurance companies, have had years and years of experience. The second thing that we provide is the National Directory Of Medical File Review Consultants, www.filereviewconsultants.com. So physicians who want to get into this kind of work, who want to get up to speed quickly, and also want to start getting cases, I recommend you look at the directory.
Jim: Thank you very much.
Excerpted from SEAK’s stream on-demand course, How to Start, Build, and Run a Successful Disability and File Review Practice