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The MLMIC Peer Review Advantage

The following article is provided by David White and Gary P. Andelora, the Medical Liability Mutual Insurance Company (MMLIC).

MLMIC is a company which was originally formed by physicians for physicians. Since its inception in 1975, the Company has strived to be sensitive to the needs of its physician insureds.

Accordingly, the Company has a peer review mechanism in place, by which policyholders have an opportunity to appear before a panel of their peers in order to describe particulars related to their professional practice and the patient care associated with claims brought against them. This type of peer review forum has been an inherent part of MLMIC since its inception in 1975 and is unique to New York State physicians.

MLMIC’s peer review process begins in its Underwriting Department. The underwriters analyze the claims experience of all the Company’s policyholders and categorize their claims by frequency (number of cases) and severity (the value or cost of those cases), while taking into consideration the location of an insured’s practice and specialty classification. This information is then used as the basis for developing a claims summary for policyholders whose claims records indicate a need for further review. MLMIC’s Claims Department then gathers the information necessary to thoroughly review the nature and extent of an insured’s claims activity.

Once the claims summaries have been compiled, they are reviewed by the Physician Underwriting Committee for possible action on the future status of a policyholder’s coverage. This committee is comprised of physicians who are experienced in assessing aspects of exposure and methods of medical practice. Committee members review the pertinent information compiled by the Claims and Underwriting Departments, and the Physician Underwriting Committee makes a recommendation with respect to the future status of an insured’s policy.

The recommendations may be: (1) no action taken (policyholder’s coverage would remain at manual/standard rates); (2) request that an interview be conducted with the insured to make a determination for possible action; (3) the imposition of a surcharge; or, (4) non–renewal of the insured’s policy. If the Physician Underwriting Committee recommends non–renewal or surcharge, the policyholder in question is provided an opportunity to attend a meeting of his/her peers to discuss any cases brought against him/her that have been reported to MLMIC within the past 10 years.

Policyholders who avail themselves of this opportunity will be scheduled for an interview with a group of physicians who are either members of the Claims Committee of MLMIC (the Claims Committee), or, for insureds who are members of the Medical Society of the State of New York, with the Professional Medical Liability Insurance and Defense Board (the Defense Board). The respective committees will have at least one physician of the same specialty of the insured being interviewed. Both of these committees, like the Physician Underwriting Committee, are comprised of physicians knowledgeable in assessing the various aspects of exposure and methods of medical practice. They are also experienced in analyzing risk as presented by an insured.

The peer review interview is an informative and non–adversarial forum in which to discuss the underlying factors leading to a policyholder’s loss experience. During the interview, the committee generally reviews and discusses both open and closed cases involving the insured, as well as other topics, such as the content of medical charts, office records and x–rays, the diagnosis and treatment provided by the insured, and relevant office protocols. Because of the non–adversarial nature of these discussions, it has long been the position of both reviewing committees that attorneys may not attend the insured’s interview.

Following the interview, the committee members will discuss the original recommendation of the Physician Underwriting Committee and, then, will either uphold the original recommendation or recommend a new course of action to be taken regarding the policyholder’s future insurance status. The decision made by the Claims Committee or Defense Board can go in either direction, that is, the recommendation can be a more severe or less severe course of action than originally recommended by the Physician Underwriting Committee. The policyholder is subsequently informed in writing of the Committee’s final decision.

The Peer Review process available to MLMIC policyholders is unique to New York State physicians. MLMIC is the only insurer that provides an insured the opportunity to discuss, via peer review, the basis for their claim activity and the details of why an insured would have incurred unusual claim activity.

Questions and comments can be directed to the Company at (800) ASK–MLMIC.

Posted 06-13-2006 at 11:34AM

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