FAQ

The client sends us a request for services, along with the medical records for the case under review. We record the data and review the referral. If we need clarification of the issues, we will ask.

We determine the specialty based the issues mentioned by the client, then we select the consultant. In special cases, we consult with the Medical Director before making this important selection. Once the reviewer is assigned, we send them all the necessary and relevant information they need to conduct their thorough, anonymous review and notify them of the due date of their report.

Once the reviewer returns their review, we screen it for quality, consistency, and compliance with our standards. If necessary, the report will be revised. When any necessary revisions are completed, we supply copies to the client, return or destroy medical records we received from the client, file our reports, and proceed with billing.

Clients may use our generic form, their own, or write a letter with the required information: name of organization, contact person, address for results, and the specific question to be answered by the review. (i.e., Was this procedure medically necessary? Is this procedure considered experimental? Was this this a preexisting condition? etc.)

A standard or extended case review is returned to the client within twenty business days from the time it is received. An expedited case review is generally returned within 72 hours, unless a different time frame is stipulated in the contract.

Not usually. If you would like to do this, you must notify us at the time of the referral. The identities of our reviewers are kept confidential. We identify them to you by number only. We believe this contributes to the objectivity of the review.

Yes. All of our reviewers sign a conflict of interest statement and renew it regularly. When we select a reviewer for an evaluation, we use a reviewer from different geographical location than the location where the service was provided. Also, all reviewers are reminded, with each review, to return any charts in which a personal or business conflict may occur. In addition, we have a process to track our review results and monitor our reviewers, assessing their quality of and looking for trends that might indicate bias.

We will send your organization a monthly statement for all services completed.

We choose a review consultant in the appropriate specialty from our panel and mail the with a cover letter identifying the question(s) to be answered and return postage for the consultant’s report. The consultant reviews the case and returns the report to us by the due date, usually 7–10 days. We standardize the report and forward it to the client.

We have a panel of nearly 400 reviewers. A registered nurse on our staff reviews the medical record to determine the most appropriate specialty. The review consultant selected must be board certified in their area of practice, have experience within the previous year in the area of review, and have no conflicts with the parties involved in the case.

Not usually. Additional areas of discussion or concern must be addressed directly with us, and we will communicate those concerns to the client.

The identities of our reviewers are kept confidential. We identify them to clients by number only. We believe this contributes to the objectivity of the review.

The reviews tend to be primarily of two types: utilization and quality.

Insurance companies usually ask utilization questions. For example, was the surgery medically necessary? Could the patient have been discharged a certain number of days earlier? Could this service have been provided on an outpatient basis?

Hospitals generally ask quality questions. For example, was this case managed appropriately?

Each chart we send you will generally take an hour or less for the utilization issues and up to three hours for quality issues. You may specify how frequently we may send you charts or, if you are too busy to review a particular chart, you can send it back within 48 hours.

We require all of our reviewers to be board certified, involved in at least 20 hours/week of clinical practice during the previous year, have a minimum of 5 years clinical experience, and have passed our credentialing process.

We ask that you give each review your thoughtful evaluation, write a concise summary of your findings, include specific rationale for your decision, and cite references when able. We also ask you return the reviews by the due date requested, generally 7–10 days.

Yes, we reimburse the reviewer within 30 days of completion. Please contact Physician Review Organization for a fee schedule.