Matthew T. Allswede, MD, an Ingham County obstetrician and gynecologist and Medical Director of Physicians Review Organization, Inc. (PRO), believes that many of his colleagues would benefit by becoming part of this peer review team. Doctor Allswede has been a member of MSMS since 1993 and a peer reviewer for PRO since 1994 before becoming PRO’s medical director in 1998.
“The benefits are twofold: as a reviewer, you gain a better understanding of the review process and the need for appropriate documentation,” he explained, “and you also play a part in maintaining the high standards of our profession. It is much more desirable to have physicians, rather than a third party, reviewing other physicians.”
Insurance company reviews may address medical necessity, appropriateness of service or setting, quality of clinical care, presence of pre-existing conditions, and determinations of experimental and investigational exclusions. Hospitals might request external peer review when:
• They want to evaluate liability risk in certain cases
• A patient complains about a staff member
• Departmental consensus regarding a physician’s performance cannot be reached
• Appropriate expertise is not available within the system
• An appropriately qualified peer without conflict is not available within the system
• New technology or a new procedure is being used
Doctor Allswede, who has three decades of experience in peer review with PRO, debunked a common misconception among physicians that PRO is responsible for rejecting insurance claims. “PRO does not approve or reject claims. Cases referred to PRO are being appealed after previously being denied by the payer. They are rejected before they get to the review process,” he explained. “PRO reviewers are advocates of quality health care, which sometimes means the denials are overturned and sometimes they are maintained.”
He wants to remind MSMS members that PRO currently is seeking reviewers in the following specialties: cardiology, dermatology, ear nose & throat, hematology/oncology, neurological surgery, neurology, pain medicine, physical medicine & rehabilitation, plastic surgery, radiology, sleep medicine, and urology. Applicants must be board certified in their specialties, be in active practice, possess at least five years of clinical experience, retain current licensure without sanctions, and possess a willingness to give each case thoughtful consideration.