Articles

Case Review Team

Photo of Michelle Sigmund
Michelle Sigmund, RHIT, CCS
Case Review Manager
Photo of Neta Smith
Neta Smith
Senior Review Assistant
 

Peer Reviewers

From our Medical Director

By serving as a Peer Reviewer, you will be participating in improving the care for all patients, including your own. In the changing environment of health care, you appreciate that care can only be judged based on the documentation provided. The peer review process is very important. We are defining the "standard of care" for our medical community. This is not a task to be taken lightly. This review process has the potential to positively impact patients' lives and enhance our practice of healthcare.

KFMC's mission statement is simple: "Leading innovation to improve the quality, effectiveness and safety of healthcare." We strive to promote this mission by working with others in the healthcare community. Through providing high quality medical reviews and evidence based determinations, we will improve the healthcare provided to the patients in our communities and achieve our mission.

We appreciate your interest and look forward to working with you.

Jason Kimball, MD
Medical Director, KFMC

Qualifications of a Peer Reviewer

There are nine requirements an applicant must meet to be considered for placement on our Panel of Reviewers:

  1. Maintain Board Certification in the specialty for which they will review,
  2. Hold current, unrestricted license or certification as required for clinical practice in a state of the United States (KAR 40-4-42e(b)(3)),
  3. Physicians Reviewers must have a current certification by a recognized American medical specialty board (KAR 40-4-42e(b)(3)), if a specialty board exists,
  4. Must be actively providing direct patient care (KFMC),
  5. Have at least five years full-time equivalent experience providing direct clinical care to patients (FTE minimum of 37.5 hours per week),
  6. Have experience providing direct clinical care to patients within the past three years,
  7. Have "no history of disciplinary actions or sanctions, including loss of staff privileges or any participation restriction that has been taken or is pending by any hospital, governmental agency or unit, or regulatory body, that raises a substantial question as to the clinical peer reviewer's physical, mental or professional competence, or moral character." (KAR 40-4-42e(b)(4)),
  8. Completion and return of the Application to Review and attestations (KFMC),
  9. Must be approved as a Reviewer by the KFMC Medical Director or Credentialing Committee (KFMC).

At the time of application, additional self-reported information is provided by the applicant and includes, but is not limited to, basic identifying information such as name, address, contact sources, NPI, sub-specialties and the length of time providing direct patient care and dates indicating when the direct patient care occurred.

Additionally, PRs should:

  • Be reasonable and fair-minded.
  • Possess a good general understanding of the healthcare delivery environment and a commitment to quality.
  • Be willing and able to devote the time required.
  • Be flexible, willing to be called on short notice if necessary.
  • Possess excellent judgment.
  • Have the ability to keep things in perspective, look at the whole picture, and determine importance.
  • Have the finesse to provide constructive criticism.
  • Have the willingness to confront another physician when appropriate and necessary.
  • Be well respected as clinicians by their peers.
  • Provide educational feedback when appropriate.

Application

Please complete and submit the This document requires Adobe Acrobat Reader to open. Peer Reviewer Application. If your credential is not an MD, DO, DPM, DOC or other physician, please complete the This document requires Adobe Acrobat Reader to open. Health Care Professional Other than Physician (HCPOTP) Application.

Credentialing - We Verify our Peer Reviewers' Credentials

Credentials verification serves three functions:

  1. Initial credentialing is the evaluation of an individual's application for participation on the KFMC panel of Peer Reviewers (PRs).
  2. Re-credentialing/re-verification assesses the individual reviewer's qualifications for continued participation as a Reviewer.
  3. Ongoing monitoring of license and certification actions, as well as sanctions or disciplinary actions, assures that only those reviewers meeting the program requirements will provide review services.

Annually KFMC will verify your licensure within your area of practice. Every three years, KFMC will update self-reported information as in the initial application form and require new attestations.

Training

Training material is contained in the This document requires Adobe Acrobat Reader to open. Peer Reviewer Orientation Manual. With your application, you will return an This document requires Adobe Acrobat Reader to open. attestation indicating that you have reviewed and understand the document.

Please pay close attention to the training section titled "Roles and Responsibilities of a Peer Reviewer."

Credential Status Changes

Credential status changes will usually be captured in reports addressing licensure or certification status; however, some will be self-reported. Consistent with the policy of maintaining a panel of qualified reviewers, KFMC PRs must notify us within three business days of any adverse change in licensure or certification status. IR 3(a) Adverse changes include not only loss of a license or board certification, but also any sanction or disciplinary action related to their credentials and loss of hospital privileges or pending hospital action. Notice of an adverse change can be provided in any form i.e. written, phone call, fax.

An adverse change in licensure, certification, or sanction/disciplinary action is treated as any other piece of confidential information. Reviewers who are levied with an adverse change of this nature are considered out of compliance with qualifications to participate as a Reviewer with KFMC.

A copy of the form, This document requires Adobe Acrobat Reader to open. Self-Reported Adverse Change in Licensure, Certification or Sanction and Disciplinary Action, is provided with the application.

Reimbursement

Peer Reviewers are reimbursed at an hourly rate for the actual time reviewing a medical record. We must have a current This document requires Adobe Acrobat Reader to open. W-9 for you on file.

Conflict of Interest

With your application to be a Peer Reviewer, you must complete and return a detailed This document requires Adobe Acrobat Reader to open. Conflict of Interest form. If you have any questions regarding a potential or actual conflict of interest, do not hesitate to contact the Case Review Manager at KFMC -- 800-432-0770 ext 366.

If you become a Peer Reviewer, you will have to complete and return another Conflict of Interest attestation form with every case you review. This action is both a reminder and a confirmation that to your knowledge, you have no potential or actual conflict to provide an unbiased, professional review on each case in hand.

Some very basic Conflict of Interest examples would be:

  • Previous involvement in the case,
  • Association with the hospital at which the care was provided,
  • Prior conflict with the physician involved,
  • Affiliation with the physician involved in the care,
  • You are in economic competition with the physician involved.

For more information, call 800-432-0770, ext 366 or contact us by email.

 

Case Review

KFMC's Case Review Program provides objective peer review and opportunities for related education. Through high quality medical review and evidence based determinations we work to improve healthcare provided to patients in our communities. Case review is made up of dedicated staff of healthcare professionals including nurses and coders. Physician consultants are available to carry out a complete and unbiased peer review of healthcare records, answering questions of appropriateness of care, quality of care, medical necessity, and coding. KFMC has 35 years of valuable experience providing peer reviews services to government and private sector clients. Our goal is to meet the needs of our customers and provide them a valuable product.

If you are a hospital, physician office, or payer looking for an outside peer review resource, please contact our Case Review Manager, Michelle Sigmund, at 800-432-0770 ext. 366. She would be happy to discuss your needs and how KFMC could help your organization.

The case review program is composed of three lines of service:

  • Independent Review Organization (IRO)
  • Independent Peer Review (IPR) and
  • Other case review services, including abstraction services.

Independent Review Organization (IRO)

  • External review is independent reviews of adverse decisions by a third-party administrator, a health insurance plan, an insurer or a health care provider acting on behalf of an insured that a proposed or delivered health care service, which would otherwise be covered under an insured's contract, is not, or was not, medically necessary or the health care treatment has been determined to be experimental or investigational.
  • Internal review is the independent review of an appeal review by an insurance issuer or group health plan or their designee (i.e., such as a third-party administrator) of an adverse benefit determination.

Independent Peer Review (IPR)

  • Independent peer review provided to hospitals, health systems, ambulatory surgery centers and other providers as they engage KFMC as a part of their internal quality improvement and quality assurance/risk management process to provide an objective, unbiased assessment of the care provided to assure standard of care is met.

Other Case Review Services

Other Case Review services are designed to meet individual client needs by request such as focused review or clinical case abstraction.