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Peer Review Sessions in Pennsylvania

Posted on February 28th, 2016

What is a Peer Review Session?

When a motor vehicle accident occurs, injuries, information, and the accident itself need to be analyzed. Often there are disputes over who was the at-fault party and how much damage they are liable for. One method that is often used by insurance companies to evaluate monetary damages based on injuries is a peer review system.

Under law, a Peer Review Organization (PRO) is a professional organization with which Health Care Financing Administration (HCFA) or the Commonwealth contracts for review of Medicare or Medical Assistance services, or a health care entity approved by the Commissioner, that engages in reviewing medical files for the purpose of determining that medical and rehabilitation services are medically necessary and economically provided.

It is also possible that Peer Review could be abused by a insurance company to deny or delay payment for medical services for treatment of injuries to a victim of a motor vehicle accident. This, at the most basic level, is unfair to those clients who are paying for insurance coverage protection provided by the insurance company. The peer reviews analyzing the client’s own doctor’s diagnosis will typically dispute the injury claims, coming to the support of the insurance companies who hire them. The result is that the injured party becomes entitled to less insurance money to cover their medical expenses, leaving them in a financially vulnerable position.

It can be argued that insurance companies have tried to avoid payment by conducting a peer review of one of our clients’ subsequent medical care. They usually decide that the treatment received was not covered by our client’s insurance. Our office attempts to combat these peer review tactics, which are unfavorable to our client’s financial recovery, in a number of ways. One way is under the Pennsylvania Code, Section 1797(b)(2) which indicates that an insured may request a reconsideration by the PRO of the PRO’s initial determination within 30 days. This proposes that a client disagrees with the Peer Review determination and that the client’s injury claims are genuine.

The doctor you trust should be the one making a determination on your injuries, not merely a doctor who is overlooking your files and records to verify your already made diagnosis. That reviewing doctor will never meet you nor see your actual health conditions and therefore should not have permission to decide whether or not you deserve the insurance money that you pay for and should rightfully have.

Contact an Experienced Accident Lawyer in Philadelphia

At Ciccarelli Law, our Philadelphia car accident lawyers are both passionate in what they do and compassionate in their treatment of their clients. For more information or to schedule an appointment with a member of our firm, contact us at (610) 692-8700 or toll free at (877) 529-2422.