Writing a report that is efficient, focused, timely and easy to understand is one of the most challenging aspects of peer review. Our Carriers have certain expectations of what they will pay for when the reports are billed hourly. Here are some ways to guide you in your review process.

• Look at the time frame in question that the Carrier is asking about and tailor your approach to correspond with that date. Pay special attention to the dates in question as the claim may have been paid prior and up to that date so the Carrier is aware of the history. This is why a brief recap of the history works, for example if the question is asking for your opinion July 2023 and forward, you do not need to include the remote
  history back to 2019; a summary recapping highlights will suffice. We realize that you need to know the history so that you can have a clear understanding of what has happened, but not all of the history needs to be included in the report. That is why under the Documents Reviewed section, the heading “I have reviewed the submitted X Number pages of records in their entirety, including but not limited to” has been added.
• It can be helpful to start your review by reading the newest information as the records tend to be repetitive. This way you now have a clinical picture of the claimant.
• There is generally a lot of duplicate information in the file, internal contact information and fax cover sheets, this can be skimmed.
• When including general information about a condition or diagnosis, it is best to keep it concise and easy to understand. This is preferred by the Carriers since the claim analysts are non-clinical people.
• For the Synopsis, include 2-4 sentences on what the condition is that the claimant is claiming impairment.
• For the Medical History pertinent office visit findings such as treatment, diagnostics, abnormal exam findings, etc. should be noted.
• For the Restrictions and Limitations, include most current with the Attending Physicians name and date.
• Recap of the Attending Physician phone call should include AP contacted, date, time, who you spoke with and a summary of the discussion.
• Stay in your lane and do not address conditions etc. that are beyond your specialty. You may document “I defer to the appropriate specialty.”
• Abbreviations are okay for common terminology but please spell out (the first time you use it) for anything unusual or specialty specific (e.g. EHL, MTP, PFTs).

A reminder: if you notice anything on the referral form (or in the records) that seems to be an error or inconsistent (names, dates, review period) please reach out as soon as possible to the Referral team and/or the QR team for assistance.

Thank you,
The QR Team

Please visit our Consultant Resources page for more information.