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A Peer Review ("chart review") is completed when a face-to-face medical evaluation is not possible or required and questions are raised regarding an injury, diagnosis, level of impairment, or appropriateness of medical treatment. Peer Reviews may be requested in relation to health insurance plans, Workers' Compensation, Auto/Casualty Liability, and Disability concerns. In completing medical peer reviews, members of our network of over 1500 qualified consultants and physicians—specialty-matched for each review—compile complete medical histories and provide evidence-based, comprehensive reports.
MCN is a URAC-accredited Independent Review Organization providing internal and external appeal reviews. Visit the Utilization Review page of our website for more information on these peer review services as well as on changes in federal law under 2010's health care reform legislation, the Patient Protection and Affordable Care Act (PPACA).
Peer-to-peer conversations are a request for additional review of a determination performed by the reviewer from the original decision, based on submission of additional information or a peer-to-peer phone discussion.
Some medical evaluations call for review by more than one physician/consultant specialty type. In this situation, MCN would complete a “Peer Panel Review,” or review by multiple specialists.
Pharmacological reviews are completed when there are questions concerning a patient’s pharmaceutical prescriptions: their appropriateness, whether they meet the best current standard of treatment, length of patient usage, and assessing any possible contra-indications and other possible harmful interactions between different prescriptions.
Radiological reviews can range from x-rays to MRIs and are requested when there is debate regarding the date or exact nature of injury. MCN’s radiological reviews are performed solely by board-certified actively practicing radiologists.
Expert witness reviews (sometimes referred to as "physician advisory reviews") are conducted on behalf of state medical or health boards to aid in the investigation of provider complaints. MCN uses specialty-matched, board certified (where applicable), actively-practicing providers to review complaint details and determine whether standards of care for the specialty in question were upheld.
A peer review requested under Act 6 of the Pennsylvania Automobile Reform is a review of a treating provider’s care by a specialty matched, Pennsylvania licensed reviewer to determine the appropriateness and/or medical necessity of care. Act 6 Reviews can only be requested in the absence treatment goals or expectations from the treating provider, when treatment duration and frequency appears excessive for the given diagnosis or without effective changes in the patient’s condition, and in cases of poor or insufficient documentation, multiple providers, or duplicate services.
By New Jersey Law, people injured in auto accidents are required to provide their insurance carrier with information regarding their medical treatment, allowing pre-authorized reimbursement for necessary testing, treatments, and care for their injury. Decision points are like mini stop signs along the way for a claim; once you get to X amount of time, you need to get X type of evaluation. Before treatment is rendered, the insurance company will require the treating provider to submit documentation to be reviewed by a doctor from the same specialty. Any denial of treatment is allowed an appeal, requiring the treating provider to discuss the findings with a reviewer different from the one who completed the determination.
MCN coordinates peer reviews on medical bills submitted under New York’s No-Fault law. With respect to Peer Reviews conducted pursuant to NY No-Fault rules and regulations, MCN ensures that, where applicable, a carrier issues a completed Denial of Claim Form (NF-10) within the 30-day period required by law. The peer review is an important tool for the claims adjuster in better understanding the medical files associated with a case as well as determining if treatment has been necessary based on the objective findings. Insurance companies can utilize this tool to cancel No-Fault insurance benefits if outcomes show extended or unnecessary treatment.