What Is An Insurer Peer Review

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An insurer peer review, in the context of personal injury claims, is a process where the insurance company hires an independent medical professional – typically a doctor in the same specialty as your treating physician – to evaluate your medical records and determine if your treatment is “reasonable and necessary.” It’s crucial to understand this isn’t an objective assessment. While presented as impartial, these reviewers are almost always contracted by the insurance carrier and have a vested interest in minimizing payout.

These reviews often occur after an initial denial or undervaluation of a claim. The insurance company will cite specific treatments they deem excessive, questioning the link between your injuries and the recommended care. They may request detailed records, imaging studies, and even independent medical evaluations (IMEs). The outcome of this peer review significantly impacts the value of your claim, and can unfortunately, lead to further delays or a complete denial of coverage.

I’ve practiced personal injury law in San Diego for over 13 years, and I’ve seen firsthand how insurance companies leverage peer reviews to devalue legitimate claims. I was previously trained by defense attorneys, providing me with intimate knowledge of their strategies—including the subtle ways they manipulate the peer review process to their advantage. Knowing how they think is half the battle.

What should I do if my insurer requests a peer review of my medical bills?

If your insurance company requests a peer review, don’t panic, but don’t simply comply without understanding the implications. First, gather all your medical records and ensure they are complete and accurate. It’s important that your treating physician is aware of the review and has a clear understanding of your treatment plan and why each procedure is necessary. Provide your doctor with a copy of the insurance company’s request so they can address any specific concerns raised.

Next, consider having your attorney review the request and potentially communicate with the insurance company on your behalf. We can help ensure the reviewer receives all relevant information and that your rights are protected. Insurers often use vague or overly broad requests in an attempt to obscure the true purpose of the review. Furthermore, they may selectively present information to influence the outcome.

Be cautious about providing any recorded statements during this process. These statements can be used against you later, even if you believe you are simply explaining your treatment. Insurance adjusters are skilled at eliciting information that can be used to devalue your claim.

What are the common tactics used in an insurer peer review?

Insurance companies employ several tactics during peer reviews to minimize their financial liability. One common strategy is to focus on the cost of treatment, rather than the medical necessity. They may compare your bills to regional averages, attempting to argue that your treatment is more expensive than comparable services. Another tactic is to question the causal link between your injuries and your medical condition, suggesting that pre-existing conditions or unrelated factors are responsible for your symptoms.

They might also scrutinize the qualifications of your treating physician or challenge the appropriateness of certain procedures. It is also common for reviewers to utilize outdated medical guidelines or cherry-pick information from your records to support their conclusions. We have encountered cases where they even attempt to discredit your doctor by raising minor, irrelevant issues about their practice.

Another method insurance companies use is selecting reviewers who have a pre-existing bias towards minimizing payouts. Their networks consist of doctors who routinely side with the insurer, making a fair assessment unlikely. This can significantly influence the outcome of the review, especially if your treating physician’s recommendations contradict the reviewer’s findings.

Can I challenge the results of an insurer peer review?

Yes, absolutely. Challenging the results of an insurer peer review is a common part of the claims process. If you disagree with the reviewer’s findings, you have the right to appeal their decision. Your attorney can help you gather evidence to support your case, such as additional medical opinions, expert testimony, and documentation of your treatment plan. We can also submit a written rebuttal to the insurance company, outlining the flaws in the reviewer’s assessment.

Appealing can also involve requesting a second peer review from an independent medical professional of your choosing. This can provide a more objective evaluation of your medical condition and treatment. However, insurance companies are often reluctant to approve a second review, so it may be necessary to pursue legal action to enforce your rights.

Remember, the burden of proof ultimately lies with the insurance company to justify their denial or undervaluation of your claim. If they cannot demonstrate that your treatment is unreasonable or unnecessary, you may be entitled to full compensation for your medical expenses, lost wages, and pain and suffering.

What happens if the peer review determines my treatment is not medically necessary?

If the peer review concludes that your treatment is not medically necessary, the insurance company may deny coverage for those services. They might also retroactively deny previously approved treatments, requiring you to reimburse any amounts they have already paid. This can create a significant financial burden and add further stress to an already challenging situation.

It’s vital to understand this does not mean the end of your claim. Your attorney can help you explore your options, including filing a lawsuit to challenge the insurance company’s decision. We can argue that the peer review was biased, incomplete, or based on flawed methodology. We can also present evidence demonstrating the medical necessity of your treatment and the significant benefits you have received.

Furthermore, we will thoroughly investigate whether the insurance company followed all applicable regulations and procedures during the peer review process. If they failed to do so, it may be grounds for a bad faith claim, entitling you to additional damages beyond your original policy limits.

What is the difference between a peer review and an Independent Medical Evaluation (IME)?

While both peer reviews and Independent Medical Evaluations (IMEs) involve an independent medical professional examining your medical records, they serve different purposes. A peer review, as previously discussed, focuses on the reasonableness and necessity of your treatment, primarily based on your existing records. An IME, on the other hand, involves a physical examination by a doctor chosen by the insurance company to assess your current condition and the extent of your injuries.

IMEs are often more comprehensive and intrusive, requiring you to travel to the doctor’s office and undergo a thorough evaluation. The doctor will review your medical history, perform a physical examination, and potentially order additional testing. The results of the IME can be used to challenge your treating physician’s diagnosis, dispute the severity of your injuries, or deny your claim altogether.

It’s crucial to be prepared for an IME and to have your attorney present to protect your rights. We can advise you on how to answer questions, what information to disclose, and how to address any concerns raised by the examiner. Remember, the insurance company’s goal is to minimize their liability, so it’s important to approach the IME with caution and to seek legal guidance beforehand.