Subject: PEER REVIEW PROCESS QUESTION

From: [email-masked] (Romel Cordeiro)
Date: Wed, 15 Mar 1995 14:41:55 -1000

I have a question that I would like to send out there and would like some
feedback from other health practitioners (or people familiar with this)
concerning the peer review process.  There has been cases where a health
practitioner's treatment/treatment plan has been questioned by insurance
companies while treating No-Fault injury patients.  It then gets sent to the
Peer Review process and gets denied.  The catch is that the denial is made
by a health practitioner who is not in the same field.  

In other words, the title of "Peer Review" loses all its meaning as the
treatments are NOT being judged by your PEERS; but by a person, though in
the health field, is not qualifed, trained and generally not educated enough
in your field of medicine to adequately give accurate opinions and most of
all; decisions whether your treatment plan was justified.  An example of a
case is where you would have a M.D. reviewing a treatment protocol done by a
chiropractor; or a chiropractor doing the same to an acupuncturist, physical
therapist, etc.  

We are gathering information to try to pursue a hearing on the state level
here in Hawaii to clarify or to further define in greater detail these
points.  There is already in existence a Hawaii Revised Statute stating that
a Peer Review Organization HAS to include representation from the profession
of the provider who services are subject to review.  However, NO WHERE does
it state that this certain individual from the same profession should be the
one giving the judgement and making the decision whether to approve or to
deny.  So you then have some instances, for example, where it states on the
Peer Review decision statement that there IS representation from this
particular Peer Review Organization from your particular profession, but it
was reviewed and signed by ANOTHER totally different health practitioner
who, again, isn't qualified to make these decisions and hasn't stated
ANYWHERE that your peer has even seen the documents or been consulted.  

We would greatly appreciate any feedback from anyone out of state who has
seen the hypocrisy of this review process and has enacted legislature to
amend it.  Maybe there is someone out there who knows of someone familiar
with or has some experience or information to help in this situation.

Waiting to hear from you.

Nimai Lins