A peer review is a review of a medical case by a Physician Advisor to ensure that the care provided by a primary physician was appropriate and aligned with Medical Necessity Criteria. Medical Necessity Criteria are sets of criteria which physicians utilize to determine the best recommended course of action for their patients.
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When you visit your physician they may approve certain care for you. This could include medications, operations, therapy, or other medical procedures. In order for the physician to receive reimbursement for this care, your case may be sent to a Physician Advisor for peer review (or physician to physician case review).
The Physician Advisor will examine your case during the peer review process and make sure that the recommendations for care assigned to you via your physician are what will most adequately meet your needs as a patient. The Physician Advisor will additionally assist in determining how likely your care is to be authorized. Authorization is coverage, or approval, by your insurance company, Medicaid, or Medicare.
Authorization is important because it allows the Physician who is treating you to be reimbursed for the services that they provide to you. Authorization also ensures that your medical insurance will cover the procedures and care that you have received.
Patients have rights: If your care was submitted for peer review, and was denied by either a Physician Advisor or your insurance company you should talk to your healthcare coverage provider to see what can be done to appeal the denial.
