What does "peer review" entail in medical insurance claims?

In the context of medical insurance claims, "peer review" involves a structured process where medical treatments, procedures, and claims are evaluated by qualified professionals, typically fellow healthcare providers with expertise in the relevant medical field. This professional assessment is essential in determining the appropriateness, necessity, and effectiveness of the treatments provided to patients.

Peer review serves multiple purposes, including ensuring that the treatments align with established medical guidelines and standards, confirming that claims submitted to insurers are based on medically necessary procedures, and helping to maintain quality and ethical standards in healthcare. It is a crucial mechanism for safeguarding both patient care and the financial responsibilities of insurance companies, as it assists in identifying any deviations from accepted practices.

This approach distinctly contrasts with perspectives or evaluations made by laypersons, which could lack the necessary medical context and expertise. It also differs from a review conducted solely by insurance agents, who may focus more on the financial aspects rather than medical validity. Lastly, it is not about examining financial records, as that involves an entirely separate process related to accounting or auditing rather than the clinical evaluation of treatments and their justification.