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PEER REVIEW: A CORE VALUE OF MEMBERSHIP
PART II: CLOSED CLAIMS PEER REVIEW

The CAP Peer Review processes continue to be a membership safeguard and a key element in this physician-directed organization.

The first Quarter 2004 edition of CAPsules dealt with the Peer Review process of the Mutual Protection Trust. Peer Review fulfills a statutory and contractual responsibility to the Members of the Trust at large by evaluating, in the context of continued and future risk sharing:

“[T]he qualifications of any physician or surgeon to continue to participate as a Member of MPT.” Peer Review policy is predicated by the terms of the MPT Agreement.

We also want to acquaint Members with another part of the Peer Review structure of MPT — the Closed Claims Peer Review process. The Closed Claims Peer Review process was instituted by the Board of Trustees of MPT in February 2003 and is initiated with every claim closure. Review at this point allows MPT to identify claims trends as well as to evaluate Members’ claims frequency and severity issues.

The Closed Claims Peer Review process includes the following:

Identification

Criteria approved by the MPT Board of Trustees are used to screen each claim after its closure. This criteria includes payments made on behalf of the Member and includes both indemnity (money paid to a plaintiff) and expense payments. Members frequently fail to appreciate the costs incurred in the defense of a claim. The amount spent by CAP to defend a Member in a trial, even if a defense verdict is obtained or the case is dismissed, can be very expensive. Members may also be referred to the Closed Claims Peer Review Committee if the Member’s claims frequency is greater than average for the specialty.

Closed Claims Peer Review Meeting

The Closed Claims Peer Review Committee meets quarterly to consider cases when the above criteria indicate the necessity of a closer review. This Committee is made up of the Chairmen of the four Peer Review Committees: Obstetrics, Orthopedics, Surgery and Medical Peer Review. The Closed Claims Peer Review Committee considers, individually, the issues in each Member’s claim and his or her claims history. As with other Peer Review Committees, deliberations do not end with an evaluation of cases or whether a particular case could be successfully defended. Even claims which can be successfully defended may reveal problems in a Member’s medical practice which expose MPT to unreasonable risk of further liability. Conversely, even when there is liability on a Member’s part, review of the facts and circumstances of the case may not indicate any increased future risk to MPT. That is why only physicians evaluate these issues and make recommendations.

After discussion, the Committee’s recommendations to the Board of Trustees may include imposition of a surcharge on a Member’s assessment, co-payments on future claims, or other practice conditions. If it is felt that the Member presents a greater risk to MPT, the Committee may instead refer him or her to an in-person Peer Review meeting. The Closed Claims Peer Review Committee, however, is not empowered to recommend termination of any MPT Member.

Recommendations Reviewed by Board of Trustees

Prior to imposition of any of the above conditions, all recommendations are reviewed and considered by the Board of Trustees. The Board of Trustees has the authority to revise the recommendation or return the matter to the Closed Claims Peer Review Committee for reconsideration. If the recommendations are upheld by the Board of Trustees, the Member will be advised in writing of the action.

Members who disagree with the imposed conditions may submit a written letter of appeal for consideration by the Committee at its next meeting. After review, the Committee will uphold or reverse its original recommendation and communicate the changed recommendation to the Board of Trustees for its review and approval.

If the Member disagrees with the reconsidered decision, the Member may request a full inperson meeting with a Peer Review Committee.

Timeframe of Conditions

Any financial conditions imposed are fixed and remain in effect for a period of three years from the date implemented. However, Members who have received conditions from the Closed Claims Peer Review may be referred to Peer Review if further claims or other negative activity warrants.

Peer Review is a Key Process

The CAP Peer Review processes continue to be a membership safeguard and a key element in this physician-directed organization.

Questions about this article may be directed to Randie Minovitz, R.N., Manager of Peer Review, at 213-473-8748.

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