I’m Jim Mangraviti. I’m here 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 peer review?
Steve Babitsky: It is a review requested by insurance companies, IROs and other companies in which a physician is hired on a contract basis to review medical records to answer questions by the client. It may be about utilization review, it may be about reasonable necessary treatment, it may be about other issues similar to that, so it’s the kind of thing that’s done on a paper review. There’s no physician patient relationship. The client sends you electronically a question, sends you the records, asks you to answer certain questions, and you answer those questions and send it back to them.
Jim Mangraviti: Now, why is it really important that a peer review or a file review be well written by the doctor?
Steve Babitsky: Well, the client has certain questions they need answered. For example, if somebody is going in for treatment, they may be trying to get a knee replacement, they may need 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. Now that could run 30, 50, 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?” It could 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 Mangraviti: Can you give our viewers an idea of what a well written peer review looks like?
Steve Babitsky: 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 or 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, and in addition, you need to know contractual language, so if they need to have so many migraine headaches a year then you have to put that in your analysis. These are the kind of things which are important.
Jim Mangraviti: Can you maybe go over three mistakes that you commonly see in docs when they’re writing peer reviews?
Steve Babitsky: 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 doctors answer questions that are not in the request, so they might ask you about disability and the doctor gets into cause 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 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 can actually cost them a lot of money.
Jim Mangraviti: Well what resources does SEAK offer for doctors that are either doing file reviews or want to get into this work?
Steve Babitsky: We have two main resources. The first is a course that we have, “How to Start, Build and Run a Successful Disability 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 and had years and years of experience. The second thing that we provide is a national directory of medical file review consultants, www.filereviewconsultants.com. So, physicians who want to get into this kind of work, they want to get up to speed quickly and also want to start getting cases, I recommend you look at the directory.
Jim Mangraviti: Thank you very much.