A number of concerns have recently been raised regarding Florida's Peer Review Committee (PRC). The committee, under the auspices of the Florida Licensing Board, conducts initial review of cases that may involve overutilization, fraud or abuse. This is where third-party payers send cases they believe involve inappropriate care. If the committee believes there are potential statute violations, the case is referred to the Probable Cause Committee for further consideration.
The PRC is comprised of seven Florida chiropractors. Six of the committee members are also consultants for DRS, a utilization review company. Some serious accusations have been made about the relationship between DRS, those six committee members, and the propriety of the peer review.
DRS employs a number of chiropractors to conduct peer reviews and independent medical exams (IMEs) throughout Florida. It pays each examiner $125 for a paper peer review to determine medical necessity, and $250-$450 for an IME to determine the patients physical status.
Based on reviews by DRS consultants, the insurance carrier may decide to send a case to the Peer Review Committee. While it is not their policy, sometimes a DRS consultant will make such a recommendation to the insurance carrier.
In addition to peer reviews and IMEs, some insurance companies also pay DRS $725 to prepare the case file for the PRC, $500 of which is paid to the committee as a filing fee. The remaining $225 goes to preparing and "sanitizing" the case file, i.e., removing all identification of provider, insurance company, patient and any consulting physician. Some contend, however, that even with sanitization, the Peer Review Committee can still identify DRS files by their format.
Some DCs in Florida believe that DRS is making a substantial financial gain by getting a large numbers of cases to the Peer Review Committee, but records from the Florida Office of Internal Audit seem to contradict that. In 1993, DRS reviewed 2041 cases with 178 (nine percent) going to the PRC. Through October of 1994, DRS has reviewed 1575 cases with 125 (eight percent) going to the Peer Review Committee.
"I have not seen any evidence that there is a conflict of interest," said Ronald Scott, DC, chairman of the Peer Review Committee.
Dr. Scott described the process: The files are sent to each individual member, with one member being assigned as a primary reviewer. Primary reviewers are assigned on a rotating basis. The primary reviewer prepares an in-depth report based on his findings of the file and those areas required by law. The primary reviewer then reports the findings to the full committee at a publicly announced meeting.
"If in the initial review of the file the staff has determined that a member of the committee may have a conflict of interest, that member will be excused and each individual member of the committee will complete a committee form called 'no conflict of interest' at the time of the meeting," Dr. Scott explained. "This gives individual members a chance, as they are reviewing files, to discover any potential conflict they may have in the review of that file."
Staff attorneys at the time of the meeting again ask the full committee, on the record, if during the review of any files in preparation for the meeting, if they have discovered any conflict.
"I have seen members excused through the staff review process, said Dr. Scott, "and I have also seen members excuse themselves after they have begun their review. In any review process, it is up to the credibility of the individual member and I have a high regard for the credibility for the members of this committee."
But who would be the beneficiary of a conflict of interest? The members of the Peer Review Committee receive only $50 per day for the committee meetings they attend. Clearly, if any one stands to benefit, it would be DRS.
We interviewed Donald Schreiner, president and CEO of DRS, about the potential for conflict of interest under this scenario.
"DC": There have been several claims that there is a conflict of interest between DRS and the Florida Peer Review Committee, would you please comment?Taking Mr. Schreiner's statement to heart, we asked Peer Review Chairman Dr. Scott what he thought of prohibiting DCs on the PRC from working for utilization review companies.Dr. Schreiner: "In response to Dr. Hoffman's inquiry (Dr. Hofman is chairman of the Flordia Chiropractic Licensing Board), we wrote a memo to everyone who is in our network and on Florida's Peer Review Committee stating: 'To avoid any further accusations or concerns, we will not assign work in the form of peer review to those members.'"
"DC": How can DCs in Florida be assured that there are no conflicts of interest on the Peer Review Committee?
Mr. Schreiner: That Florida Peer Review Panel reviews sanitized files. We also sanitize our files to our reviewers. That alleviates all bias. Secondly, in an effort to maintain objectivity, we randomly rotate doctors' cases to different reviewers and when possible, we send the reviews outside the doctors' immediate area."
"DC": We're told you attend the peer review meetings. Some see that as an inordinate interest in the proceedings? Why do you attend the meetings?
Mr. Schreiner: "The reason I attend (peer review) meetings is that we are very concerned with the issue of profiling (tracking repeat offenders)."
"DC": There has been some discussion that those chiropractors who serve on the Peer Review Committee should not be allowed to work for utilization review companies such as DRS, how would you respond to this?
Mr. Schreiner: "It would be very unfair to the members of the peer review board. But if that would alleviate the concerns of the chiropractic profession, we would respond immediately. And I am sure the members of the peer review board would understand the rational behind this decision. After all, the members of the peer review board are there to protect the public."
"I believe that it would be a tragedy to the review process and profession to limit their individual rights for fear that some one might believe that they would not do a credible job in performing their civic responsibility."
Mr. Schreiner stressed that the individual members on the committee are highly regarded and leaders in the profession and are "here basically on a volunteer basis having been appointed by the Secretary of the Department." He expressed confidence that committee members would have no problem discontinuing any of their private activities if this was a requirement.
While we've received reports of potential conflicts of interest in the Peer Review Committee, our inquires have found no hard evidence to substantiate those claims. Yet the questions of impropriety linger, and concerns over conflicts of interest will disappear only if the opportunity for abuse is eliminated.
The answer is simple: The Florida State Board (and all other state boards) should consider regulations that would prohibit board members from working for utilization review companies.
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