How Does an Independent Review Organization (IRO) Define "Peer Review"?

 


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Peer review is used in many industry sectors to delineate the use of people who are peers within an industry or an organization who review and judge a person’s performance, work product or other behavior. Peer review has been used for years as a part of academia to review professor’s qualifications and credentials. Peer reviews have also been used in other circles such as accounting and finance. But in the area of health care, peer reviews commonly refers to physicians who look at medical cases in order to make an objective third party decision.

Peer review is also a substitute for the phrase “independent medical review, ” where physicians are looking at cases to provide claims decisions for health insurance payers, workers compensation insurance payers, disability insurance payers, etc. Peer review also defines the review of sentinel events in a hospital environment for quality management purposes, such as looking at bad outcomes and determining whether there was any misdiagnosis, mistreatment or any systemic problems involved which lead to that event.

Peer review, independent medical review, hospital peer review, medical peer review, all of those terms are really interchangeable today. Unfortunately in the healthcare environment everybody uses their own vocabulary to talk about the same thing. Today “Peer Review” at AllMed Healthcare Management is really a substitute for the words that we prefer to use, either “independent medical review” or “hospital peer review”. In either case, the core peer review function is to take physicians who are not a party to a particular treatment but who are board certified and in active practice in that same area of treatment, and have them examine certain cases in order to provide objective, unbiased determinations on what the root cause of the treatment was—whether or not there is medical necessity, if there was a sentinel event, what was the reason for it, etc.

I hope this clarifies the use of those different terms.

About AllMed Healthcare Management
Founded in 1995, AllMed is a URAC-accredited Independent Review Organization (IRO) serving insurance payers, providers, TPAs and claims managers nationwide. Reviews are conducted by board-certified physicians in active practice. AllMed's growing customer base for its independent medical review and hospital peer review services includes premier organizations, such as Educator's Mutual Life, IMS Managed Care, Tenet Healthcare Corporation, HealthGuard, several Blue Cross Blue Shield organizations, TriWest Healthcare Alliance, Allianz and many other leading healthcare payers. Read the AllMed Medical News Blog and the Independent Review Organization Blog .

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