Medical peer review is important in validating the objectivity and justice in healthcare decisions, specifically for the denial of medical claims. With such a process, clinical information is compared against clinical guidelines internationally accepted and against evidence-based medicine to ascertain the appropriateness of these medical treatments. It should have a significant role in health insurance plans, healthcare providers, and patients.
In-house peer review or outsource it from an independent review organization or medical review company may be some of the options organizations could choose. But which is better? The blog compares the benefits and challenges provided by both solutions for healthcare stakeholders to enlighten decisions.
Understanding the Medical Peer Review
Medical peer review is a systematic process in which a reviewing physician reviews medical decisions, claims, and treatments regarding said medical intervention is referred to as medical peer review. The healthcare service rendered should fall within coverage requirements and conform to evidence-based medicine modalities. It is a method that affords the following: minimizing medical errors, risk reduction, and overall safety improvement. This is also the determination of whether a treatment meets the requirements of a health insurance plan.
In-House Medical Peer Review Solutions
Internal peer review involves a specialty physician internal peer review team for conducting this type of review in an organization- a healthcare provider, insurer, or hospital. Hence, it offers a direct approach for the organizations to maintain control of the review process. Because internal reviewers are well-acquainted with organizational policies, it becomes an easier task to align decisions with company-specific protocols.
Challenges Faced by In-House Medical Peer Review Teams
Benefits are associated with in-house peer review; however, it raises serious challenges in this area:
- Insufficient Expertise: Sometimes, an internal team does not include specialty physicians from various medical areas. Therefore, gaps develop in the specialty.
- Internal Bias: Internal review may not be transparent for insurers and providers and thus raises issues about fairness emerging.
- Resource Intensive: Building an internal peer review team consumes huge resource investments for administrative support, training, as well as compliance with HIPAA.
- Time Lag: The review of claims and appeals is delayed because reviewing physicians are usually saddled with other responsibilities within an organization.
Outsourced Medical Peer Review Solutions
The outsourcing method of medical peer review involves collaboration with an independent agency independent review organization, or a medical review company. Using such agencies gives access to highly qualified specialty physicians who conduct objective reviews or evaluations according to industry-accepted clinical guidelines.
Advantages Offered by Outsourced Peer Review Solutions
Several aspects render outsourced peer review attractive for providers and insurance organizations:
- Broader Pool of Experts: External agencies have a broad network of peer review physicians from a wide range of medical specialty areas.
- Objectivity and Transparency Improved: An outsourced peer review provides an impartial assessment that helps minimize the potential for bias.
- Cost-effectiveness: Working with an external agency also cuts down the overhead of staffing, training, and maintaining an internal team.
- Faster Turnaround Time: Foreign peer reviews tend to be speedier compared to internal peer reviews, helping to accelerate the resolution of medical claim denial issues.
- Enhanced Compliance: Medical review companies demand strict adherence to HIPAA compliance, coverage guidelines, and evidence-based medicine practices.
Comparative Analysis: In-house vs Outsourced Solutions
| Feature | In-house Peer Review | Outsourced Peer Review |
| Specialty Expertise | Limited to in-house specialists | Broad network of specialty physicians |
| Objectivity | Potential for internal bias | Independent and objective assessments |
| Cost Efficiency | High operational and staffing costs | Lower costs with scalable solutions |
| Turnaround Time | Delays due to workload constraints | Faster reviews with dedicated resources |
| Compliance & Regulations | Requires continuous training to stay compliant | Industry-standard compliance guaranteed |
| Scalability | Limited by internal capacity | Easily scalable to handle varying workloads |
Case Studies / Real-world Examples
Case Study 1: Health Plan Member Satisfaction Improvement
Member Satisfaction Improvement at Health Plan
The health insurance plan above was dependent on the in-house peer review; the company had long delays in claim resolution, and decision making was inconsistent. By outsourcing peer review to an independent review organization, claims turnaround time improved by 40%, and there was greater transparency regarding the insurers and health providers. Consequently, this resulted in higher member satisfaction with fewer negative determinations.
Case Study 2: Reducing Liability Risks for a Hospital Network
A network of multi-hospitals experienced an increasing amount of legal liability due to medical errors in its review process held internally. Partnering with a medical review company greatly reduced litigation cases and significantly lowered liability risk due to creating implementation of the evidence-based medicine guidelines.
Conclusion
Choosing between in-house and outsourced peer review depends entirely on what an organization deems necessary. Although an organization controls its in-house operation, there are problems of specialization, bias, cost factors, and efficiency. On the contrary, outsourced peer review is a scalable, cost-effective, and unbiased option that grants an organization access to specialty physicians along with improved compliance.
Partner with a seasoned medical review company and enhance your peer review processes because it guarantees accurate, timely, and transparent reviews. Call us now to learn how our outsourced peer review solutions can improve your operations and decision-making!
