Peer review, independent medical review, hospital peer review, and medical peer review, have all become interchangeable terms in the healthcare industry. As is often the case, different organizations and individuals use their own vocabulary when talking about the same thing. As a general rule, the term “Peer Review” has become a simplified substitute for all the phrases listed above. Whatever you prefer to call it, the core function is to utilize the objective determinations of physicians who are not a party to a particular treatment, to approve or deny medical claims based on medical evidence and following accepted standards of care. These physicians must be board-certified and in active practice.
Independent review typically (but not always) occurs after all appeals mechanisms available within a health benefits plan have been exhausted. Independent review can be voluntary or mandated by law.