Best Practices   /   October 2019

Peer Review Committee Q&A – What You Need to Know

Peer Review Committee Q&A – What You Need to Know

The goal of the Peer Review Committee (PRC) is to ensure an objective review of care and conduct performed by other practitioners, in order to enhance the quality of patient care. Similar to the Credentialing Committee, the PRC is made up of practitioners with similar specialties to those being reviewed, and the ultimate objective should be the improvement of patient care through practitioner education and health system improvement.  The conduct and process of peer review should seek to identify possible system improvements that an organization could implement to help reduce the chances of mistakes or adverse events.

Q: So, what is the Peer Review process? 

A: Peer review is a process where outside providers evaluate the quality of their colleagues’ work to ensure prevailing standards are being met. The majority of peer review happens retrospectively.   Peer Review conducted by health plans, medical staffs, medical groups, etc. should be confidential and protected but the evidence and clinical decision making that is used in developing any peer review decisions should be transparent. 

Q: What does the Peer Review Committee do?

A: The Peer Review Committee reviews a specific issue or complaint received from a member, patient or provider. The items reviewed include departures from standards and guidelines or deviations from generally accepted community medical standards. These issues have the potential to adversely affect the patient.

Based on standards of care, medical necessity, the scope of practice, experience, and levels of care, the PRC will make a fair determination of the next steps or consequences. All peer review activities are kept confidential, and so information disclosure is limited to the involved practitioner or to those individuals requiring access to the data in order to perform any recommended corrective action.

Q: What does the Peer Review Committee typically recommend? 

A: After the review of the PRC is completed, the PRC can either find the provider’s treatment and services were appropriate and no further action will be taken, or that the provider’s treatment was not appropriate. If the treatment is deemed not appropriate, the PRC can place the provider on a Corrective Action Plan.  As stated above, the end product of peer review should be the improvement of patient care through practitioner education and health system improvement. The process of peer review should seek to identify potential system improvements that an organization could implement to reduce chances of mistakes and to avoid potential adverse events.


CredSimple can assist you with the Peer Review process by obtaining the Primary Sourced information and additional information regarding the provider during the Credentialing process.

 

Similar Articles
Nov 05, 2019

Breaking It Down: What is credentialing?

  1.What is Managed Care/Health Plan Credentialing? Credentialing is the process of obtaining, verifying and…

Oct 26, 2019

7 Steps to Get Your Credentialing Committee Up & Running

Perhaps you're part of a team helping to start up a new health plan, or…

Oct 04, 2019

3 Things to Know About a Typical Credentialing Committee

What is a credentialing committee, and what is it comprised of? A Credentialing Committee is…