Physican Review
Physician review means that you get an expert opinion from a qualified board certified
practitioner that is a specialist in the area of medical examination and treatment for the case that is under review. Not only are the reviewers licensed physicians in particular practice areas, they must be board certified as well and have been in active practice for no less than five years before they are qualified to serve on a review board.The individual physician that is a reviewer is also subject to peer review. They make the initial analysis of the cases that are assigned to them, but that is not the end of the process. In addition to their opinion about the professional level of care administered in a particular case or the lack thereof, there is another step that occurs to insure the compliance with the standards of care practices that are necessary to maintain the desired quality levels. This is the overall case review by the board of examiners, where they look for patterns and anomalies of care exceptions that might indicate a systematic problem.
If for example a particular reviewer has a rejection case rate higher than expected then their cases will be further analyzed in every detail to try to understand what are the fundamental issues. Perhaps there is a misinterpretation by the examiner, or perhaps there is a significant problem that is an organizational issue that needs to be addressed. Either way, the methodologies of case analysis and the fundamental statistical parsing of the data sets will highlight the situational case methods that need further scrutiny.
A quality physician review will pinpoint case failures but will not overstate problem areas due to some lack of expertise or unstated bias. This is the fundamental value of having a quality physician review. If the organization is operating at a high level of efficiency then the physician review will confirm the same, and only if there are problems, mistakes, misdiagnosis for example, procedural violations or the lack of application of standard best practices protocols will the physician review point those out in their reports.
This is exactly what is wanted form a high quality physician review to highlight the exact case where further scrutiny needs to be applied to understand the situation and any fundamental or structural problems.
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