Peer review for insurance companies

[Phantom Spike]

Does anyone here have experience working as a peer reviewer for insurance companies and the like? On the face of it, it seems like an easy way to make some extra money working remotely/from home on your own schedule, but are there any major pitfalls to be kept in mind? I guess legal liability is a big one, but you're generally covered by the company's insurance policy (which I don't believe is a standard malpractice policy so I'm not sure how robust it is), and I'm told that since you don't establish a patient-physician relationship, you can't really be named in a lawsuit. Does your name ever go in the patient chart? How often do you need to speak with the referring physician and do you find those conversations stressful? Are there any pressures from the employers themselves (to deny as many cases as possible, etc.)? How long does it generally take you to review a case? Do you get to select cases you're comfortable with and are within your field?

Bottom line, is peer review something you would recommend doing for those considering it?

---

Members don't see this ad.

 

[neglect]

Does anyone here have experience working as a peer reviewer for insurance companies and the like? On the face of it, it seems like an easy way to make some extra money working remotely/from home on your own schedule, but are there any major pitfalls to be kept in mind? I guess legal liability is a big one, but you're generally covered by the company's insurance policy (which I don't believe is a standard malpractice policy so I'm not sure how robust it is), and I'm told that since you don't establish a patient-physician relationship, you can't really be named in a lawsuit. Does your name ever go in the patient chart? How often do you need to speak with the referring physician and do you find those conversations stressful? Are there any pressures from the employers themselves (to deny as many cases as possible, etc.)? How long does it generally take you to review a case? Do you get to select cases you're comfortable with and are within your field?

Bottom line, is peer review something you would recommend doing for those considering it?

If you're honest, they'll fire you right away because you'll trust the doctor who's actually seeing the patient.

The patient and I want Gilenya, the insurance company wants Copaxone. And if you're up against me, get ready for a fight. Also better hide your phone number - because I will give that to the family if I have it. And your name will certainly go into the chart with proper spelling. Because if harm befalls my patient and YOU denied care, I'm going to Call Saul and will be happy to testify for free during a deposition that you harmed this patient by getting in the way of my treatment plan.

I will be happy to tell you this during our phone call. I NEVER hang up. I like to schedule these calls for times when I'm not busy, like over lunch when I'm going for a walk or driving home. I really take my time explaining my thought process on this patient. And telling you, politely and with a smile, that what you are doing is evil - because you are dictating care without seeing the patient, without explaining things to the patient, without being in the same room as a patient.

It is such a lovely thing to actually hear burnout on the other side of the phone. I've had people hang up on me, which is literally the best thing ever, because then I write letters! (I'm insufferable, really, truly horrible, but in an adversarial relationship, I'm hammer >>> nail). Go ahead, hang up on me, then expect a letter to the patient and to your insurance company bosses about how I'm TRYING to have a peer to peer discussion to benefit my patient, but it couldn't happen because you hung up on me and this is not acceptable.

It is regrettable when they just cave right away.

 

[A Mysterious Stranger]

If you're honest, they'll fire you right away because you'll trust the doctor who's actually seeing the patient.

The patient and I want Gilenya, the insurance company wants Copaxone. And if you're up against me, get ready for a fight. Also better hide your phone number - because I will give that to the family if I have it. And your name will certainly go into the chart with proper spelling. Because if harm befalls my patient and YOU denied care, I'm going to Call Saul and will be happy to testify for free during a deposition that you harmed this patient by getting in the way of my treatment plan.

I will be happy to tell you this during our phone call, which I like to have over lunch or when I'm driving. I NEVER hang up. I like to schedule these calls for times when I'm not busy, like over lunch when I'm going for a walk or driving home. I really take my time explaining my thought process on this patient. And telling you, politely and with a smile, that what you are doing is evil - because you are dictating care without seeing the patient, without explaining things to the patient, without being in the same room as a patient.

It is such a lovely thing to actually hear burnout on the other side of the phone. I've had people hang up on me, which is literally the best thing ever, because then I write letters! (I'm insufferable, really, truly horrible, but in an adversarial relationship, I'm hammer >>> nail). Go ahead, hang up on me, then expect a letter to the patient and to your insurance company bosses about how I'm TRYING to have a peer to peer discussion to benefit my patient, but it couldn't happen because you hung up on me and this is not acceptable.

It is regrettable when they just cave right away.

You’re evil... I love you.

 

[Telamir]

I thought this was an April Fool's joke since it was posted on April 1st. Honestly, you're not going to get much sympathy here or an honest answer because this is widely (and I think rightfully) considered to be scummy as all hell. People who do this are not highly regarded and rightfully so. I don't encounter these much since I do inpatient only, but back in training I had the same approach as Neglect. When I got called I'd take down the number of the person I was talking to and plaster it all over the chart. Honestly: **** people who do this.

 

[Phantom Spike]

Thanks, everyone, for your responses. I mean that sincerely and my original post was genuine, not meant to be a joke or trolling.

I'm still in active clinical practice myself, and have dealt with peer reviewers as a requesting provider for years. Most of the time I'm able to convince the reviewer to authorize the requested service by simply stating my reasoning for it. Sometimes not, but on those occasions, the reviewer usually provides a roadmap rather than an outright denial ("we'll approve a CT head first, and if that doesn't give you what you need we'll authorize the MRI you want", or "if the patient fails a trial of gabapentin we'll authorize the pregabalin", or recommending a trial of autoCPAP before an in-lab CPAP titration study in patients with straightforward OSA and no co-mobidities, etc.). I've never personally gotten into a shouting match or felt that the reviewer was putting the patient's care in obvious peril or that they were evil or motivated only by the insurance company's interests to the exclusion of all else (if that happened frequently I would never have opened up this thread). And I've seen a lot of cases where a patient had, for example, two EMGs in six months of each other with no changes in symptoms, or an MRI cervical spine ordered in a patient with neck pain and a non-focal exam, or an MRI brain in a migraine patient or a dementia patient with normal CT head, where the requested expensive test would not change management.

I guess it's a little like the argument for defense lawyers; without the peer reviewers, would there ever be scope for appeal? In starting this discussion, I was also hoping to hear the other side from someone who actually does this, to see how much pressure there was from the insurance companies/third party employers to always rule one way, whether they ended up threatened by lawsuits, the quality of the insurance provided, etc.