Peer reviews are a helpful tool to address questions of injury relatedness and causality. Recently, an Injured Worker’s (IW) claim was discussed at Grand Rounds with ACP’s Medical Director, Dr. Avrom Gart. Dr. Gart had previously reviewed the associated medical reports and documentation submitted by the Case Manager on the claim. During the Grand Round’s discussion, Dr. Gart pointed out that the injured worker’s back symptoms were caused by the IW’s pre-existing and genetic conditions and not by the injury described.
The adjuster requested a peer review be completed to formally document the Medical Director’s review. The completed Peer Review report that outlined the lack of causality for the back injury was sent to the Adjuster who was preparing for settlement. The Adjuster was able to use the Peer Review report as the basis to dispute the back as a covered body part to the claim.
The Adjuster agrees that without the Peer Review discussion of causality issues and the subsequent formal report, the costs to settle the claim would be significantly higher.