How to Respond to a Medical Peer Review

Physicians working in today’s managed healthcare industry can expect their performance to be subject to close scrutiny. Often this involves having charts and cases regularly examined by their professional peers. In most circumstances, peer reviews are a routine method of ensuring patient safety and quality of care. Though they usually reflect a health care entity’s responsible pursuit of patient complaints, patterns of conduct, or other potentially minor inquiries into a physician’s practice, reviews may also follow incidents of patient injury or mismanagement. However, given the subjective nature of peer reviews and the multifarious rivalries that exist among physicians at many top flight hospitals, peer reviews can also manifest professional biases or even provide administrative cover for political jockeying or worse.

It is up to a physician to determine whether a notice of peer review is a cause for concern; however, because an unfavorable finding can have serious consequences on a physician’s career, it is best to know your rights ahead of time. If you receive notice of a medical peer review, how should you respond?

Under the Health Care Quality Improvement Act of 1986 (HCQA), you are entitled to a hearing before an officer, panel, or an arbitrator mutually acceptable to both you and the health care entity issuing the review, provided you make your request for a hearing within the thirty days following your notice of review. If a request is made, the health care entity will provide you with a second notice detailing the time, place, and date of the hearing, scheduled at least thirty days in the future. This notice will include the names of the hearing officer or panel and a list of any witnesses expected to testify at the hearing.

You have the right to be represented by an attorney or any other person of your choice at your hearing, as well as to call witnesses to testify on your behalf, examine and cross-examine witnesses, and produce evidence supporting your position. At the conclusion of the hearing, you may also submit a written statement on the matter of review. The proceedings will be recorded and you have the right to access this recording, as well as the right to receive the health care entity’s final written decision.

While the HCQA is a federal law, your state may have further legislation on what protections are available to you with regard to professional reviews. Your employer or health care entity may also provide information on professional review policies in its bylaws. If you have been given notice of a review – especially if you have been accused of misconduct or have reason to expect disciplinary action – you may wish to secure representation by a qualified attorney, who can help secure evidence and witnesses, defend your position during the review, and work with you to ensure a fair hearing.

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