The Insurance Company Is Doing a Peer Review of My Doctor - What is That?

After a car accident in Pennsylvania, your medical bills are covered under your own policy up to the medical coverage limits. This is called first-party or "no fault". Part of what you paid premiums for all those years was for medical bills if you get in an accident (regardless of who was at fault). The insurance industry lobbied for, and got passed, a law that allows for "peer reviews" of medical bills. This means that your insurance company can contest whether your doctor's medical treatment is reasonable and necessary. Unfortunately, there is great potential for abuse by insurance companies. There is a conflict of interest in that your insurer wants to save money on claims but they've already collected your premium money. Worse, they get to pick a doctor to do the peer review. So, they aren't using a court-appointed doctor. You typically have no say, nor does your doctor, in which doctor is chosen. If the insurer is puts its own interest in saving money over your health interests, do they choose the same doctors over and over who they know will tend to give them reviews that say they don't have to continue paying for treatment? Under the peer review rules (see PA Motor Vehicle Financial Responsibility Law). you and your doctor have the ability to ask for a reconsideration of a negative peer review. However, you will have to pay the cost of the reconsideration if the peer review doctor confirms their previous opinion. From our experience, the reconsideration rarely results in a change in the peer review decision. The costs, then, have a "chilling effect" on most people's willingness to request reconsideration. Your treating doctor should remain proactive with the insurance company. Your doctor should, as a best practice, stay in contact with the medical adjuster to try to prevent your treatment from going into a peer review.