Section 1797 of the Motor Vehicle Financial Responsibility Law (MVFRL) introduced a new concept regarding paying medical providers for care rendered to motor vehicle accident victims in 1990. The new law established what a provider can accept as payment for services rendered. It also provided for a peer review to be used y insurance companies if they did not agree with the “reasonableness and necessity” of the treatment provided. Section 1797(a) established what fee could be charged by the provider, namely “110% of the prevailing charge at the 75th percentile; 110% of the applicable fee schedule, the recommended fee or the inflation index chart; or 110% of the diagnostic-related groups (DRG) payment;… determined to be applicable in the Commonwealth under the Medicare program for comparable services at the time the services were rendered or the provider’s usual and customary charge, whichever is less.” §1797(b) requires insurance carriers to contract jointly or separately with a peer review organization (PRO). The PRO in turn contacts a peer reviewer to review documents provided by the provider to the PRO.

PRO’s are regulated by 31 Pa. Code §69.53 in relevant part as follows:

· (a) a PRO is to reimburse providers for copying records at the current rate RCFA reimburses its contracted PRO;

· (b) written notice of determinations are to be mailed to the insurer within three working days of the conclusion of the peer review;

· (c) a PRO shall apply national or when appropriate, regional norms in conducting determinations and when national or regional norms do not exist, the PRO shall establish written criteria to be used in conducting its reviews based upon typical patterns of practice of PRO’s geographic area of operation; and

Peer reviews apply to Pennsylvania as well as out of state providers.