Independent medical review
From Wikipedia, the free encyclopedia
“Independent Medical Review" is the process whereby physicians review medical cases in order to provide claims determinations for health insurance payers, workers compensation insurance payers, or disability insurance payers, etc. Peer review also is used in order to define the review of sentinel events in a hospital environment for quality management purposes such as to look at bad outcomes and determine whether or not there was any mis-diagnosis, mistreatment or any systemic problems involved which lead to the sentinel event.
Physicians who perform independent medical reviews must be Board Certified and in active practice in that same area of treatment. These physicians are contracted by an Independent review organization, medical management companies, third party administrators (TPAs), or utilization review / utilization management companies 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.
Terms that medical professionals use that are synonymous with "Independent Medical Review" include "External Medical Review", "Medical Peer Review", "Peer Review", or Hospital Peer Review(if the sentinel event happened at a hospital).
[edit] References
- 10 Reasons To Use An Independent Review Organization
- State of California Independent Medical Review FAQ's
