A peer review is typically a review and critique by one expert of another expert’s opinion. In order for this critique to have any merit, of course, it must explore the basis of the opinion and point out why the expert’s opinion is wrong.
In the world of ERISA, however, a physician peer review is, more often than not, a purchased opinion intended to support a termination or a denial of benefit by an insurance company. For example, if a treating physician provides an opinion as to her patient’s restrictions and limitations, then a peer review of that opinion should point out any problems with the opinion with specific reference to findings in the medical records which point to a different, or contrary, conclusion than the one asserted by the treating doctor. There may also be reference to medical or scientific literature, which might reflect that the treating doctor overlooked something. However, this is not what occurs the overwhelming majority of the time.
Instead, insurance companies will often hire a doctor to espouse a different opinion than the treating doctor without ever having examined the patient, and of course without ever pointing out why the treating doctor was wrong. The purchased opinion is often “boiler-plate” language or conjecture designed to support a prior decision made by the insurance company. Insurance companies do this because the claim procedure regulation requires that they utilize a qualified medical professional on an appeal. The purpose of the regulation, in my opinion, is to require fair evaluation of the treating physician opinions. Buying an opinion to support a preordained decision falls short of this. Nonetheless, this is what occurs in many of the cases we see. We are keeping track of the doctors doing this but their ranks are growing. It is easy money for the doctors, and certainly much easier than treating patients and worrying about reimbursement from health insurance carriers.
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