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Policy Compendium

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View Practice, Organization & Interprofessional Policies

REQ-004: Third Party Medical Review

 
Third Party Medical Review: The Wisconsin Medical Society reaffirms its policy of continuing to seek uniform procedural standards and requirements for all organizations utilizing medical review to approve or deny health insurance benefits for medical care. The Society believes these organizations should be required to:

  • Register with the state of Wisconsin.
  • Make review criteria available to health care professionals and patients.
  • Obtain licensure for all medical care reviewers along with requiring adequate education and training in the areas that they are reviewing.
  • Clearly delineate the appeals process available to both patients and health care professionals.
  • Fully disclose any financial incentives that the reviewers might have based on denying a target amount of services or health care professionals.
  • Prior to any adverse determination regarding medical necessity or appropriateness of care, provide the physician with an opportunity to discuss the plan of treatment with a physician reviewer in the same specialty, during normal working hours.
  • Assure patient confidentiality and present authorization to the physician for release of patient information to the review organization. (HOD, 0410)*

 
*Currently under five-year policy review.