The significance of this ruling for your practice is that once an IME is performed indicating the patient/insured has recovered, the carrier can cut off payments to you for any further care. (William vs. Allstate Insurance Co, U.S. District Court for the Eastern District of Pennsylvania, 2:08 – CV – 03031 – RB.).

A federal judge has predicted that the Pennsylvania Supreme Court will eventually rule that an insurance carrier can discontinue medical payments if the insured does not submit to a reasonable medical exam.  By way of background, this case involved an insured with Allstate who refused to undergo an independent medical exam when requested to do so by Allstate.  The insured refused to go to the IME because Allstate had not obtained a Court Order requiring the insured to do so, even though there was a provision in the Allstate policy allowing Allstate to require the insured to submit to an IME or face discontinuance of coverage.  The federal judge relied on a Pennsylvania Superior Court case that stated when a policy for car insurance contains language which explicitly states the carrier can compel an insured to attend an IME, such a provision is enforceable without the need for the carrier to obtain a court order.  Many carriers, e.g. Nationwide, are performing a peer review and buttressing their position to discontinue payments with an IME.

1.         Clear, Concise and Non-repetitive Documentation

Many providers used canned software to document an office visit. While writing reports is boring and irksome, in the long run it pays off. Providing individualized information about a patient rather than pre-canned language, as well as putting an anecdote in the patient’s file, such as not being able to lift up his child when the patient returned home at night, goes a long way towards keeping the well-known peer reviewers at bay.

2.         Reasonableness and necessity versus causation

It is clear from both the language in the statue and the Insurance Commission’s regulations interpreting the statute that only reasonableness and necessity of the care rendered by the provider can be discussed in the peer review. Issues such as the setting and/or frequency of the treatment can be discussed in the peer review. Ascribing the care to preexisting pathology or lack of substantial impact with minimal property damage at the of time of the accident goes to etiology or causation and cannot be discussed in a peer review.

3.         Timely Compliance with all aspects of Act 6

Every time requirement in Act 6 must be strictly complied with. This means that the bills must be sent out by the carrier to the PRO within 30 days of receipt. It also means that the carrier has 90 days to collect all the material for reviewing, including contact with the provider under review. The reviewer than has 30 days to complete the review, unless an additional 20 days has been requested. The PRO then has 3 days to mail the review to the carrier, who in turn must mail the review to the provider within 5 days. If any of these dates are not strictly complied with, the peer review is invalid and the provider must be paid. This means that the substantive issues raised in the peer review need not even be addressed.

4.         Take the Phone Call

The peer review process requires some communication between the peer reviewer and the provider. While there is dispute as to whether the reviewer or the provider is to initiate the phone call, the provider should always take the call when the reviewer calls to go over the file. The provider should then explain to the reviewer why the care was mandated and what the results were of the care under question. At the very least coming to the phone by the provider prevents the defense attorney from arguing to the Judge that the provider had something to hide.

5.         Notice to Provider

Each provider who submits bills must have an individual peer review performed. This means that if an MD refers a patient to a physical therapist, the MD and therapist have to have individual peer reviews performed for the care of each of them. It is not enough that the referring provider is reviewed, since the carrier may try to use this review to not pay care rendered by the physical therapist.

6.         Make Sure the Reviewer Has All the Documentation

Too often there is valuable documentation in the patient’s chart that the reviewer is not sent. Consults, results of radiological tests, and in-house testing, should all be sent to the reviewer. Doing so enables the reviewer to see the big picture as seen by the provider during the course of treatment.

7.         Review All Entries Made by Staff

The number of times providers have been embarrassed on the witness stand because of erroneous or sloppy entries made by their staff have occurred all too often in my practice. A quick but thorough review of any entry made in the patient’s chart by a staff member will pay enormous dividends in the long run.

8.         Repetitive Treatment Without Signs of Change

Many reviewers criticize the provider’s continuation of treatment, particularly physical therapy, without the patient showing signs of improvement. While it is recognized how intractable a patient’s condition can be, some indication should be made in the chart as to why the provider thought the patient should continue to need the same form of treatment with the same frequency. A periodic consult by a specialist will often provide the ammunition necessary to rebut any criticism that a reviewer may have as to why the same treatment is required.