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The Health Care Financing Administration has decided to launch a pilot study testing an innovative physician peer review of denied Medicare claims proposed by the California Medical Association (CMA). "There’s a sense of injustice and abuse that has become fairly common in the physician community, and the development of a pilot study to address some of our concerns will help to deal with that," comments Melvyn Sterling, MD, chairman of the CMA’s Medicare Evaluation and Management Technical Advisory Committee. "Physicians are just really angry and upset, and that’s not helpful in resolving our issues with HCFA."
According to a HCFA letter to the CMA, ". . . we are designing a pilot program intended to determine whether the outcomes of medical review determinations are substantially different when performed by specialty physician reviewers as compared to the current system of employing nurse reviewers." Present plans are to have the pilot ready for testing before next fall.
This peer review concept, known as the California plan, was an outgrowth of physician dissatisfaction with HCFA’s 1997 proposed evaluation and management documentation guidelines.
Under the CMA plan, physicians from the same specialty as the practitioner whose claim was denied would perform a peer review focusing on "outliers," or those physicians whose claims don’t fit a normal billing profile, notes an analysis by the American Medical Association. This would then be backed up by education efforts to help physicians understand why a carrier denied their claims, where appropriate.
Currently, carriers usually use nurses to perform claim review, only calling in a physician for especially difficult cases.
While many physicians feel they will end up winning more questioned claims with fellow practitioners conducting the review, some experts predict there will be no major change in audit results. In fact, physicians may even end up losing more appeals because doctors tend to be stricter reviewers than nurses, says Gerald Rogan, MD, medical director for National Heritage Insurance Co., California’s Medicare carrier.