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PEER REVIEW:
A CORE VALUE
OF MEMBERSHIP
PART II:
CLOSED CLAIMS
PEER REVIEW
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The CAP-MPT
Peer Review
processes
continue to be a
membership
safeguard and a
key element in this
physician-directed
organization
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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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