Date: Sun, 12 May 1996 03:27:29 +0000
From: H Kenneth Gilbertson <hkgdc@i1.net>
Subject: Re: peer reviews

At 12:04 PM 5/11/96 -0400, you wrote:
>You may be in violation of new laws governing obscenity in cyberspace with
>your use of the word below.  I have always felt the word was too harsh and
>began using a more learned, gentler term of prostitute.
>
>Recently I have felt even that was too harsh.  I suggest we refer to them as
>"doctors of the evening."
>
>R. Dean Harman, DC
>
>In a message dated 96-05-11 10:14:44 EDT, Drjimchiro@aol.com writes:
>>>peer review whores
>>
>>We are experiencing the same type of peer reviews here in Pennslyvania.
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If you feel that a DC that has reviewed your claim is not on the up and up,
the only way to stop him/her is to challenge their review. There is a
general commonality among most reviewers that we have had contact with (not
all):
1. most of them have small practices otherwise they wouldn't have the time 
   to review claims.
2. Most of them look at the case as to "how can I cut this claim", rather
   than is this justified?
3. Many of them make comments or render opinions they can't support.
4. Most of them don't want you to know who they are.
5. Most of them don't want to talk to the treating doc.

We have a policy, if our claim is cut and we feel it's unfair we want to
speak directly to the reviewing doctor. We're nice about it mind you but we
want to discuss it with the reviewer. We frequently find that there is a
misunderstanding about something or the reviewer has made a decision about
something he knows little about. IN SOME CASES, the insurance company just
won't let you talk to the reviewer and they make some silly statement like
"if you have additional information we will be happy to re-review".
That's just plain silly we could be writing letters back and forth for 75
years at the rate insurance companies process their paper.
If the insurance company won't cooperate send them a certified letter:
 Dear Ms. Insurance:
We have tried to get to the bottom of what we feel is unfair handling of
this claim. We have requested that you allow me to talk to the reviewer of
this case so that we could handle this matter in a fair uncomplicated
manner. Since you are not willing to cooperate we will have no other choice
then to bring suite against you. We wish you would reconsider all that we
are requesting is to speak to the doctor who has stated that services
were....unnecessary...excessive or what ever reason he has given.

Usually this will put you in contact with the reviewer, If it doesn't, you
now have a great letter to show the judge that will probably win you the
case. It has for me.

By the way a few years ago, one of my associates had just taken the Missouri
Certified Chiropractic Consultants program and was contacted to do reviews.
After a couple of reviews the review company said, "We can't use you
anymore, your reviews don't cut the bills enough to make it worth the
insurance expense". Interesting? 

H. Kenneth Gilbertson D.C. <hkgdc@i1.net>
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