What's A Peer Review

By Joyce Novotny-Prettiman, Esq.

After an automobile collision, your auto insurance company pays your medical bills. This streamlines the medical claim process and simplifies the task of getting your medical bills paid quickly. It does not matter who caused the accident - it is always your insurance company that has the primary obligation to pay your medical bills. Your insurance company must provide at least $5,000 in medical coverage and should offer additional coverage up to $1,000,000. (For more details, see the Fall 2006 issue of the Legal Update found on our website at www.qrglaw.com.)

Things do not always go smoothly. Many insurance companies begin to question your medical treatment shortly after you are injured in an auto accident. When this happens, the insurance company begins a process known as a "peer review" to cut off payment of your medical bills. This involves a review of your medical records by a physician who is hand-picked by the insurance company and may also involve a physical examination. When you are injured and need medical treatment to recover, this process can cause a great deal of stress.

Pennsylvania law requires that insurance companies follow specific requirements when conducting a peer review. If the correct steps are not followed and deadlines are not met, a peer review may be invalid. We challenge peer reviews for clients who have payment of their medical bills rejected based on such a review. A successful challenge to a peer review enables our clients to continue to receive the medical care they need.

Most times a peer review is conducted by a doctor who never sees the injured person; the reviewing doctor sees only medical records. If your doctor is willing to testify that your treatment is reasonable, it may be possible to defeat the peer review. You need to know that, as a patient, you can challenge an unfavorable peer review ruling. Also, you cannot be billed for medical treatment during the peer review. Finally, a medical provider cannot charge you the balance owed if a peer review determines that provider's charges should not be paid.

The following chart shows 2005 peer review statistics gathered by the Pennsylvania insurance commissioner. This chart shows the number of initial peer review determinations requested and the percent that number represents of total determinations.

Insurance Company

# of Determinations Initiated (% of all total determinations)

Nationwide

1414 (28.3%)

State Farm

416 (8.33%)

Erie

414 (8.29%)

AIG

367 (7.35%)

Travelers

327 (6.55%)

Liberty Mutual

137 (2.74%)

If you find yourself in the situation where your auto insurance company has used the peer review process to cut off your medical benefits before you have exhausted the coverage you paid for, we will be happy to review your options with you.

At Quatrini Rafferty , we can help you with questions about your auto insurance coverage. To review your auto insurance coverage or inquire about a car accident please email a Pennsylvania car insurance attorney today, or call us at 724-837-0080 in Greensburg or toll free at 888-534-6016.

For more information on Pennsylvania auto insurance, please visit our Car Accidents Information page.

For more information on auto accidents, please visit our Motor Vehicle Accident Information Center.

Related articles on Pennsylvania auto insurance & auto accidents:

Flexible Insurance Coverage

Beware - All Registered Vehicles Must Be Insured

Required Auto Coverage

Limited Tort - a Bad Deal

Why is my Auto Insurance Paying my Medical Bills?

Pennsylvania Driver Alert

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  • Super Lawyers
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  • WILG
  • NOVA
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