Public Policy
PEER REVIEW
01/01/2017
(RESOLUTION 13-43) RESOLVED, that the ISMA pursue legislation that would: Require private insurers to assign an appropriate equal-level specialty or subspecialty for peer-to-peer reviews. Require a $100 fee made payable to a physician from a private insurance company that is forced into a “peer-to-peer” review in order to defend the “medical necessity” of the procedure that was ordered by the treating physician on behalf of his/her patient. (RESOLUTION 08-36) RESOLVED, that the ISMA adopt the following AMA policies on peer review: E-9.05 Due Process The basic principles of a fair and objective hearing should always be accorded to the physician or medical student whose professional conduct is being reviewed. The fundamental aspects of a fair hearing are a listing of specific charges, adequate notice of the right of a hearing, the opportunity to be present and to rebut the evidence, and the opportunity to present a defense. These principles apply when the hearing body is a medical society tribunal, medical staff committee, or other similar body composed of peers. The composition of committees sitting in judgment of medical students, residents, or fellows should include a significant number of persons at a similar level of training. These principles of fair play apply in all disciplinary hearings and in any other type of hearing in which the reputation, professional status, or livelihood of the physician or medical student may be negatively impacted. All physicians and medical students are urged to observe diligently these fundamental safeguards of due process whenever they are called upon to serve on a committee which will pass judgment on a peer. All medical societies and institutions are urged to review their constitutions and bylaws and/or policies to make sure that these instruments provide for such procedural safeguards. (II, III, VII) Issued prior to April 1977; Updated June 1994. H-375.984 Peer Review Our AMA affirms that it is the ethical duty of a physician to share truthfully quality care information regarding a colleague when requested by an authorized credentialing body, so long as the information that is shared with the credentialing body is protected by statute or regulation as confidential peer review information. Quality of care and patient safety are the goals of peer review. Peer review should address the prevention of medical errors and appropriate system changes. (Sub. Res. 93, A-88; Reaffirmed: Sunset Report, I-98; Amended: BOT Action in response to referred for decision BOT Rep. 23, A-05) H-225.992 Right to Relevant Information (1) The AMA advocates "timely notice" and "opportunity to rebut" any adverse entry in the medical staff member's credential file, believes that any health care organization file on a physician should be opened to him or her for inspection, and supports inclusion of these provisions in hospital medical staff bylaws. (2) Triggers that initiate a peer review within a health care facility should be valid, transparent and available to all member physicians and should be uniformly applied to all cases and physicians. (3) A physician accused of an infraction of medical staff bylaws, rules, regulations, policies or procedures and faced with potential peer review action shall be promptly notified that an investigation is being conducted and shall be given an opportunity to respond. (4) All relevant information pertaining to a potential peer review action should be obtained promptly from the subject physician and other relevant sources. Relevant information includes, but is not limited to, pre-event factors, names of other health professionals involved in the care of the patient, and the contributing environmental factors of the health care facility/system. (5) All material information obtained by the peer review committee regarding the subject of the peer review should be made available to the physician under review in a timely manner prior to the hearing. (6) The investigating individual or body shall interview the practitioner, unless the practitioner waives his/her right to be heard, to evaluate the potential charges and explore alternative courses of action before proceeding to the formal peer review process . (Res. 121, I-83; Reaffirmed: CLRPD Rep. 1, I-93; Modified by Sub. Res. 801, A-94; Reaffirmed: CLRPD 1, A-04; Amended with change in title: BOT Action in response to referred for decision BOT Rep. 23, A-05) H-375.965 Principles for Incident-Based Peer Review and Disciplining at Health Care Organizations AMA policy is that: (1) Summary suspension of clinical privileges is an extraordinary remedy which should be used only when the physician's continued practice presents an "imminent danger to the health of any individual." The decision to summarily suspend a member's medical staff membership or clinical privileges should be made by the chief of staff, chair or vice-chair of the member's clinical department, or medical executive committee. The medical executive committee (MEC) must meet as soon as possible, but in no event more than 14 days after the summary suspension is imposed, or before the time in which a report would be required to the state licensing agency if applicable, whichever is shorter, to review and consider the summary suspension. The MEC shall then promptly modify, continue or terminate the summary suspension. The suspended physician must be invited to attend and make a statement concerning the issues under investigation, but the meeting with the MEC shall not constitute the physician's fair hearing. If the MEC sustains the suspension, said action will trigger the fair hearing procedures contained in these policies. (2) At the request of a medical staff department or of a member under review, or at its own initiative if needed for adequate and unbiased review, the medical executive committee may arrange, through the state or local medical society, the relevant specialty society or other appropriate source, for an external hearing panel to hear the case in order to assure professional and impartial clinical assessment. (3) Prior to any disciplinary hearing, the physician should be provided with a clear, and if applicable, clinically supported basis for the proposed professional review action. A hearing panel of a health care organization should be guided by generally accepted clinical guidelines and established standards in its review actions. (4) Physician health and impairment issues should be identified and managed by a medical staff committee, which should operate separately from the disciplinary process. (BOT Action in response to referred for decision BOT Rep. 23, A-05) E-9.10 Peer Review Medical society ethics committees, hospital credentials and utilization committees, and other forms of peer review have been long established by organized medicine to scrutinize physicians' professional conduct. At least to some extent, each of these types of peer review can be said to impinge upon the absolute professional freedom of physicians. They are, nonetheless, recognized and accepted. They are necessary, and committees performing such work act ethically as long as principles of due process (Opinion 9.05, "Due Process") are observed. They balance the physician's right to exercise medical judgment freely with the obligation to do so wisely and temperately. (II, III, VII) Issued prior to April 1977; Updated June 1994. H-375.990 Peer Review of the Performance of Hospital Medical Staff Physicians Our AMA encourages peer review of the performance of hospital medical staff physicians, which is objective and supervised by physicians. Membership on peer review committees and hearing panels should be open to all physicians on the medical staff and should not be restricted to those physicians who have an exclusive contract with the hospital, salaried physicians, or those on the faculty . (Res. 57, I-85; Reaffirmed CLRPD Rep. 2, I-95; Reaffirmed: BOT Rep. 8, I-01; Amended: BOT Action in response to referred for decision BOT Rep. 23, A-05) H-375.970 Professional Review Organization Peer Review The AMA strongly recommends that public and private sector review entities conduct their reviews using evidence-based guidelines or practice parameters developed by national medical specialty societies. (Sub. Res. 719, I-97; Reaffirmation I-98) (READOPTED 08-13, HOD; RESOLUTION 98-20) RESOLVED, that the ISMA continue to support the confidentiality of peer review information. (3-22-81, BOT) That peer review of physicians be done by physicians rather than by administrative or third-party carrier interests.
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