Medical Director Corner
Your report(s) can assist the facility with regulatory and/or auditing requirements for their physician’s yearly credentialing or privileging purposes.
Clients may use these reports to look for trends in a physician’s care of his/her patients, whether it be for credentialing purposes or to look for opportunities for improvement. An external independent review provides the client with the opinion of another physician from the same specialty and offers guidance on what should (or should not) have been done. External review removes any potential bias and conflict of interest inherent in internal review.
One thing that these reviews are not used for is to actively care for a patient. And because you are not providing care of the patient, you do not have to hold a license in the state where the client is located. The only types of reviews that require same-state licensing are department of insurance IRO reviews from three states, none of which CIMRO currently has contracts with (NC, TX, and NJ).
It is possible that you may be asked to participate in a fair hearing for a review or group of reviews. In all instances, you are informed at the time the initial review request is sent to you whether there is a possibility of a fair hearing. You may use this to help determine if you are willing to review the case. Countless times, even if a case is indicated for fair hearing, it never comes to fruition. In the event a fair hearing does take place, though, your responsibility is to participate in a discussion of your review and your rationale behind your decision. This discussion is usually done via teleconference with individuals from the facility and sometimes the physician under review. These hearings can also be done on-site, if the peer reviewer is willing to do so. A fair hearing does not mean you are testifying in a court of law. The fair hearing process is part of a facility’s internal governance under the auspices of the medical staff by-laws.
CIMRO has an excellent panel of reviewers, who most often go above and beyond, when performing reviews for our organization. We are grateful to all of you who are willing to provide this extra service so that our clients can continue to provide the most up-to-date, evidence-based care to their patients. Thank you, and we look forward to working with you in 2019!
Ronald Johnson, MD
Interim Medical Director