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REP-002: Peer Review Code of Conduct

 
Peer Review Code of Conduct: The Wisconsin Medical Society approved the following code of conduct for all organizations undertaking peer review activities affecting Wisconsin physicians:

  • Peer review activities shall be carried out in a professional manner, maintained through all levels of review and communication, by both the reviewing organization and its physicians as well as the attending physician involved.
  • Peer review activity at all levels shall be based on a thorough review of the complete medical record. Denials shall be made not on failure to meet screening criteria but rather on professional review of the case as a whole. Rubber-stamping of prior review decisions without a thorough review of the medical record is to be condemned.
  • Specialty-specific review by practicing physicians shall be the goal at all levels of review beyond the initial screening. All physicians involved in providing peer review services shall be understanding of the methodology of appropriate case review.
  • Final decisions regarding recommendations for sanction activity shall be made only after a thorough review of each individual case by a physician reviewer in the same specialty as the attending physician and only following a full opportunity for the attending physician to present and discuss the total case situation with the reviewing physicians.
  • Peer review decisions shall be made based only upon that information that was available to the attending physician at the time in question. Analyzing patient care based solely on outcome and other subsequent case information is not appropriate.
  • The attending physician’s decisions must be judged on generally accepted standards of care and that the medical care provided was necessary, reasonable, and appropriate given the available resources and the individual patient case situation in question.
  • Peer review activity shall be completed expediently in each case, with similar time response constraints placed on the reviewing organizations themselves as are imposed on the attending physician.
  • All communication from the peer review organization to the attending physician shall be worded to be appropriately reflective of the seriousness of the proposed patient care infraction and appropriately reflect the appeals process available to the attending physician.
  • All peer review organizations shall develop internal quality assurance mechanisms at all levels of review to minimize the amount of inappropriate re-view which practicing physicians are subjected to. The Wisconsin Medical Society condemns overzealous review and any quota systems of review denials and supports appropriate review without quota or economic incentives to deny claims.
  • Patient confidentiality shall be maintained at all levels of review.

 
In cases of reviewer uncertainty, the benefit of the doubt in case management shall be given to the attending physician. Only the attending physician was at the scene, under the stress of the situation, and responsible for the total care of the patient. (HOD, 0411)*

*Currently under five-year policy review.