What Is a Peer Review in Workers’ Compensation?

A peer review in workers' compensation is an evaluation of your medical treatment by a physician who wasn't involved in your care. This review verifies that the treatment you received was necessary and appropriate.

Peer reviews are often requested by the insurance company handling your workers' compensation claim. They typically aim to support or challenge the treatment plan recommended by your doctor. 

Insurance companies often use peer reviews to control costs by questioning the necessity of certain treatments. While their aim might be to save money, it can sometimes result in the denial of legitimate claims. Knowing how peer reviews work can help you prepare better and advocate for yourself. 

Why Are Peer Reviews Important?

Insurance companies can use peer reviews to attempt to reduce or even deny the benefits you receive. A peer review can question the need for ongoing physical therapy, surgery, or even diagnostic tests. If the reviewing physician believes the treatment is unnecessary, the insurance company may deny coverage. This can make it difficult for you to get the medical care you need.   

Understanding the reasons behind a peer review and having proper documentation from your treating physician can be critical in contesting decisions that seek to deny coverage for your medical care. 

How Does a Peer Review Affect Your Claim?

The outcome of a peer review can significantly impact your workers' compensation benefits. If the review supports the recommendations from your treating physician, your claim will usually proceed. However, if the peer review disputes the necessity of your treatment, it can lead to delays, denials, or reductions in benefits. 

A negative peer review can be frustrating and stressful. You may have to appeal against the decision or provide additional documentation to support your case. In this case, a knowledgeable workers' compensation attorney can help you challenge unfavorable reviews and advocate for the treatment you need. 

The Peer Review Process

The peer review process typically begins when the insurance company requests an independent medical review. They will send your medical records to a physician who specializes in the type of treatment you received for your injury.  

The reviewing physician will assess the aspects of your treatment, including the diagnosis, type of care provided, and expected outcomes. They will provide an opinion about the necessity of your treatment and submit a report to the insurance company. Based on this report, the insurer will decide whether to approve or deny your claim. 

Common Issues in Peer Reviews

One common issue in peer reviews is the potential for bias. Since the reviewing physician is paid by the insurance company, there could be grounds for a conflict of interest. This could lead to unfair conclusions that negatively affect your claim. It's important to be aware of this possibility and seek legal advice if you suspect bias. 

Another issue is the lack of direct examination. The reviewing physician often relies solely on medical records without examining your injuries in person. This can result in incomplete assessments and misinterpretations of your condition. It's important to keep detailed records to help reduce this risk. 

Preparing for a Peer Review

Preparation is key when facing a peer review. Start by keeping detailed medical records of all treatments and consultations. Make sure your treating physician documents every aspect of your care, including the reasons behind each treatment. This documentation can be critical for supporting your case during the review. 

Additionally, talk to your treating physician about the peer review process. They can help you understand what to expect and provide the information you need to strengthen your claim. An experienced workers' compensation attorney can also offer insight and help guide you through the process. 

Appealing a Negative Peer Review 

If a peer review results in a denial of your benefits, you have the right to appeal the decision. The first step is to gather additional evidence supporting the necessity of your treatment. This might include medical records, expert opinions, and statements from your treating physician. 

Submit this evidence to the insurance company along with a written request for reconsideration. If your claim is still denied, you can escalate the appeal to the Missouri Division of Workers' Compensation or the Illinois Workers' Compensation Commission.

Working With Your Treating Physician

Your treating physician plays a crucial role in the peer review process, and their documentation and communication can significantly impact the outcome of your case. It's important to make sure your physician understands the importance of detailed records and provides thorough explanations for their treatment choices. 

Encourage your physician to be proactive in addressing any concerns raised during the peer review. They can write letters of support, provide additional medical evidence, and even participate in hearings if necessary. A collaborative approach between you, your physician, and your attorney can help to strengthen your case. 

Peer Reviews Laws in Missouri and Illinois

In Missouri, workers' compensation laws require medical treatments to be necessary and appropriate for the injury in question. Since insurance companies often use peer reviews to assess treatment necessity, if a treatment is deemed unnecessary, coverage may be denied. However, Missouri law allows you to challenge such denials through the state's workers' compensation system. 

Illinois has similar laws regarding workers' compensation. Treatments must be necessary and reasonable for the injury. Peer reviews are frequently used to evaluate the appropriateness of care. However, if treatment is denied based on a peer review, you have the right to appeal the decision. 

Need Workers’ Comp Representation in Missouri?

At The Law Office of Steve Slough, our attorney switched from defending large insurance companies to helping real people. With a background in insurance defense, he understands how corporations handle personal injury cases, helping us anticipate potential obstacles. He is committed to fighting for your rights and aiming for full compensation, whether settling or going to trial.

If your insurance claim has been denied due to a peer review, reach out to our firm today. Located in Clayton, Missouri, we serve clients throughout St. Louis County, St. Charles County, and Madison County, Missouri, as well as St. Clair County, Illinois. Contact us to schedule a free consultation.