September 30, 2025 - Posted on WorkCompWire Leaders Speak (Read Part One)
By Karol White, Senior Director of Operations at Emperion
Over the past several months, I have received inquiries from payers regarding the prevalence and appropriate use of Peer Reviews in Workers’ Compensation. Based on available research, it is estimated that 5–10% of all claims undergo a case specific Peer Review at the request of the claims professional. Given that the Bureau of Labor Statistics (BLS), reports approximately 2.6 million nonfatal workplace injuries and illnesses occurred in the U.S. in 2023, the prevalence underscores the value of sharing information on the value of Peer Review more broadly.
What is Peer Review?
Peer Review is an independent assessment of medical treatment plans and records conducted by a qualified healthcare professional, often a physician in the same specialty as the treating provider. Unlike an Independent Medical Examination (IME), which involves a direct physical evaluation of the injured employee, case-specific Peer Review focuses primarily on reviewing medical records, diagnostic tests, and treatment plans to render an opinion.
Additionally, it is important to distinguish between case-specific Peer Reviews (discussed in this post) and second- or third-level physician reviews often conducted as part of mandated utilization review (UR) programs.
- Case Specific Peer Reviews are typically requested at the discretion of the claims professional and focus on a course of treatment for a specific claim. These reviews are often used in complex or disputed cases to support claims decision-making.
- In contrast, second- or third-level physician advisor reviews within a UR framework (sometimes referenced as peer review) are part of a structured, state-mandated process. These reviews generally occur when a denial or modification is being recommended by a nurse for a provider’s proposed treatment the utilization review protocols. The primary goal is to ensure compliance with state regulations and standardized treatment guidelines about a specific treatment request, rather than to provide clinical insight about the course of treatment at the claims professional’s request.
Purpose of Peer Review
The primary goal of a Peer Review is to determine whether medical treatment is appropriate, necessary, and related to the work injury. This process can help:
- Clarify Treatment Plans: Ensuring that care aligns with accepted medical standards.
- Assess Medical Necessity: Identifying treatment plans that may be unnecessary or excessive.
- Support Claims Decisions: Providing objective, evidence-based medical insights for claims resolution.
- Reduce Litigation Potential: Offering expert insight that can prevent disputes or prepare for potential or planned legal proceedings.
When are Peer Reviews Used?
Peer Reviews are commonly utilized in workers’ comp in several scenarios, including:
- Medical-Only Claims: When relatedness or necessity of treatment is questioned.
- Lost-Time Claims: When an employee is off work and the appropriateness of ongoing treatment is unclear.
- Complex Medical Cases: Where multiple medical conditions may affect recovery and return-to-work outcomes.
And they are also commonly utilized in Auto or Liability insurance when claim limits are low and cost-effective guidance on medical management is needed.
How do Peer Reviews Work?
The Peer Review process typically follows the following steps:
- Referral is Made: The claims professional contacts a Peer Review company to request that a Peer Review be arranged. This request is accompanied by a specific list of questions the claims professional needs addressed.
- Collection of Medical Records: The Peer Review company gathers all relevant documentation, including planned and previous treatments, diagnostic tests, and physician notes. Typically, this is information already in the claims professional’s files and can be easily provided.
- Arranging for the Review: The Peer Review company selects the most appropriate provider, preferably from its URAC credentialed network, to perform the review and plans for it to be completed.
- Clinical Assessment: After review of the questions posed by the claims professional and all the medical documentation, the peer reviewer evaluates whether the care provided is consistent with evidence-based guidelines and standard practice.
- Provider Consultation: The peer reviewer may consult with the treating provider to clarify details or gather additional information.
- Report and Recommendations: A comprehensive report is generated by the peer reviewer, detailing findings and recommendations regarding the appropriateness, necessity, and effectiveness of the treatment.
- Quality Assurance: The Peer Review company reviews the report submitted by the peer reviewer to ensure that it addresses the specific questions asked and meets the requirements outlined.
- Report Delivery: The report is delivered to the requestor allowing them to proceed with their next course of action on the claim.
Now that we have set the stage for what Peer Reviews are, let’s review the benefits of Peer Review. Peer Reviews provide numerous advantages to payers, employers and the injured individual. However, one of the most significant benefits of a Peer Review surrounds how quickly the assessment can be accomplished. Unlike an IME, where a physical exam of the injured individual is needed, a Peer Review can be accomplished quite timely.
- No Appointment Scheduling Required
- Peer Reviews are conducted by reviewing the questions asked by the claims professional, and the medical records and documentation, so there’s no need to schedule a physical exam with the injured employee.
- If you have ever tried to schedule a doctor’s appointment for yourself, you can imagine how the need for an exam could result in longer timelines due to the availability of the injured individual and the selected examiner.
- Faster Expert Assessment
- A qualified physician can review a complete case file and provide findings in a matter of days, depending on the complexity of the case.
- IMEs generally take longer because the process includes scheduling and conducting the in-person examination, post-exam analysis, and sometimes additional testing. Additionally, if for any reason the exam must be rescheduled, the clock starts all over.
- Reduced Administrative Delays
- Peer Reviews avoid logistical steps like phone calls to check on availability, sending appointment notices, confirming plans to attend, arranging travel and/or translation, and confirming attendance after the fact.
- Expedited Claims Action
- The timeliness of Peer Reviews allows claims teams to act on recommendations almost immediately vs. needing to wait.
- Lower Cost Alternative
- Peer Reviews, due to not being reliant on a physical exam or additional diagnostic testing, can be accomplished in much less time by the reviewer and the service provider. Less time results in lower expenses being charged to accomplish the task at hand.
Conclusion
Peer Reviews play a vital role in the Workers’ Compensation ecosystem by offering an impartial, clinical perspective on medical treatment. When an examination is not necessary, they can inform claims decisions, reduce unnecessary costs, and promote safe and timely return-to-work outcomes.
For Workers’ Comp claims professionals, incorporating Peer Reviews into the claims process is not just a best practice—it’s a critical tool for achieving accurate, fair, and timely case resolutions. Next week we will explore IMEs, highlighting the steps in the process to complete them and when they are the clinical tool of choice.
About Karol White
Karol White brings more than 30 years of expertise in Independent Medical Examinations (IMEs) and Peer Review, with a proven record of leadership, customer service, and operational excellence.
Currently serving as Senior Director of Operations at Emperion, Karol leverages three decades of industry knowledge to deliver streamlined solutions and trusted support to customers across the workers’ compensation, disability, auto, and liability markets. In this role, she partners closely with clients, providers, and internal teams to ensure efficient operations, supporting successful claim outcomes.
About Emperion
Emperion is a national provider of outsourced clinical review services including Independent Medical Examination (IME), Peer Review (PR), and Independent Review Organization (IRO) solutions. The company manages a national network of approximately 25,000 providers across a broad range of medical specialties. These capabilities promote patient recovery, return to employment, and successful claim outcomes across Workers’ Compensation, Automobile, Disability, and Health benefit systems.