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“Physician Peer Reviews” Lead to Wrongful Denial of Disability Insurance Claims

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

Physician Peer Reviews are problematic because the peer review physician does not even examine you, speak with you, or get a full picture of your capabilities. Nevertheless, that doesn’t stop the peer review physician from issuing an opinion that you are 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, it could be 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 insurance company singled out only 35 pages of medical information to send to the peer-reviewing doctor. Despite the fact that our client had suffered from severe systemic lupus for over 10 years, the peer review physician could not agree that lupus existed because the insurance company 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 limited opinion from limited information. If disability insurers were more interested in proof than profit, they would be working more closely with physicians who have the greatest experience in the case (ex your treating physicians). Or they would schedule IME’s with doctors who are not professional reviewers for the insurance industry. When when we have asked for input in selecting the examining doctor, the disability insurance community has refused.

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 concluding 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 to Peer Consultation

Peer reviews will sometimes have a “peer to peer” consultation feature. This is when the peer-reviewing physician calls your doctor to ask about your condition and your medical records. The peer review physician will then summarize the conversation and report the conversation to the insurance company.  I believe peer to peer consulations violate HIPAA privacy laws.  

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 alarmed by misrepresentations and inaccuracies in the peer reviewing doctor’s summary.

The claimants treating physician should be weary of discussions with peer reviewing doctors.

 

In closing, we hope 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.

 

Questions about your long term disability insurance claim?

 Call (877)-428-9806 for a free consultation and we will be happy to answer your questions or concerns and talk about what we can do for you.

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