“Peer Reviews” Lead to Wrongful Denial of Disability Claims

A peer review is NOT the same as a second opinion or independent medical exam (IME). Essentially, a peer review is a tool used by the insurance company to review your Dr’s medical records.

Peer reviews are problematic because of the type of information that the insurance companies send to the reviewing doctor. The peer review physician does not even examine the claimant, speak with the claimant, or get a full picture of the claimant’s capabilities. Nevertheless, that doesn’t stop the peer review physician from issuing an opinion that the claimant is not disabled. This is a completely unacceptable practice that leads to the wrongful denial of disability claims.

And you would think the reviewing physician would have the same experience and credentials as your treating primary care physician or specialist. But in reality, you may find an Internal Medicine doctor reviewing your complicated Neurology case!

At McDonald & McDonald we recently had a case where the administrative record contained hundreds of pages of medical records, but the disability insurer singled out only 35 pages of medical information to send to the peer-reviewing doctor. Despite the fact that this claimant had suffered from severe systemic lupus for over 10 years, the peer reviewer could not agree that lupus existed because the insurer did not supply her with any lab work.

Peer reviews do not generate the type of medical evidence that has high quality or high value. At best, they provide a very limited opinion derived from very limited information. If disability insurers were more interested in the proof than profit, they would be working more closely with the physicians who have the greatest experience in the case (your treating physicians) or they would schedule IME’s with doctors that are not entirely beholden to the insurance industry. When we have asked for input in the selection of the examining doctor, the disability insurance community has refused our input into physician selection.

In disability practice you quickly find out that insurance companies accept peer reviews as the “gospel truth.” We recently had another case where a client had a paralyzed diaphragm. This was a substantial finding according to our client’s family doctor and pulmonologist, but the peer-reviewing physician didn’t view it as significant. The peer review resulted in the insurance company’s conclusion that “no restrictions or limitations” existed.

Possibly the most disturbing trend with peer reviews is that they are being used after your appeal is complete. I do not believe that this is a legitimate practice. Once the appeal is complete, there is very limited room for the creation of new evidence by the insurer, but that is exactly what they are trying to do. Our disability appeal work is very thorough and we usually point out the weaknesses in the insurer’s denial of the claim. We have had more than a few insurance companies use peer reviews to correct the weaknesses in their own administrative records.

Peer reviews will sometimes have a “peer to peer” consultation feature. This is a practice where the peer-reviewing physician will call your doctor and speak to your doctor about your condition and your medical records. The peer review physician will then summarize the conversation and report the conversation to the insurance company.

We recently had 2 separate cases where we sent the peer reviewing doctor’s summary to our client’s treating physician. In BOTH CASES the treating doctors were floored by the extent of the misrepresentations and inaccuracies in the peer reviewing doctor’s summary. I believe that any peer reviewing physician who contacts a claimant’s treating physician may be inviting the claimant’s treating physician to violate HIPAA privacy laws. The claimants treating physicians should be weary of discussions with peer reviewing doctors.

In closing, we remain hopeful that the insurance industry will stop its reckless use of peer reviews and peer-to-peer consults. Disabled workers deserve better than this shabby treatment.