Peer Reviews

Resolving a disability or workers’ compensation claim isn’t always easy, especially when there are multiple—and sometimes conflicting–opinions involved. The employee wants to know when they will be feeling well again and if their job is secure in their absence. The employee’s doctor may want to ensure the employee has as much time as needed to fully recover, and the claims manager wants to ensure the claim is valid and is handled fairly. While not directly involved in the claim itself, managers are wondering when the employee can return to work, as the absence may cause a disruption in work flow.


These often-diverging priorities can make it difficult to feel confident in a claims decision, particularly when it comes to behavioral claims since the illness is not overtly visible. Furthermore, if critical diagnostic, treatment and functional information isn’t complete or available, it is challenging to form an accurate picture of the claimant’s situation.


The R3c peer review process gives you an independent, objective, and evidence-based conclusion to help confidently resolve behavioral and physical health claims.


The Reassurance of an Independent Peer Review

Brittany opened Fred Walton’s claim file one more time, but it didn’t yield any more information than it had an hour ago. As a new claims manager who studied his file like she was preparing for an exam, Brittany knew Fred’s situation by heart.


Six months ago, Fred, a salesman in the regional office, had been hit by a car as he rode his bike home. The accident left him with a broken femur, and he had not returned to work since. That kind of injury could take three to six months to fully heal—a tough injury for anyone to recover from, but for a 53-year-old, recently divorced man, it was even tougher.


Even after he began physical therapy, the return to work date he gave kept getting delayed. His doctor said Fred wasn’t ready to come back, but Brittany couldn’t really tell why. Furthermore, Brittany was fielding calls from Fred’s boss, Sam, asking when Fred was going to come back to work.


But the problem was more than a broken leg. Brittany took a deeper look into Fred’s file. A few weeks after the accident, Fred was diagnosed with depression and posttraumatic stress disorder, or PTSD. The notes said Fred was seeing a psychiatrist, but there were few records that detailed the severity of Fred’s condition, a treatment plan or, for Sam’s sake, a plan for returning to work.


What was the whole story here, Brittany wondered. Were Fred’s primary care physician and psychiatrist collaborating to treat Fred? Why wasn’t more information available from Fred’s psychiatrist on the severity of his condition and how that affected Fred’s ability to do the job? Questions and more questions, Brittany thought. And very few answers.


During the last staff meeting, Brittany’s boss had announced the company had contracted with R3c—a partner vendor that could provide peer reviews to help claims managers in cases just like this, when the information available was scarce or murky and reaching a claims decision was particularly challenging.


Brittany could reach out to R3c and have them look at Fred’s case and provide a balanced, independent, and unbiased review of the case.


Brittany felt relieved. She didn’t have to have all the answers for the case, but she now had a resource to get them.


The R3 Continuum Advantage

R3c identifies a clinical expert who reviews the case, including reading medical records, interviewing the claimant, and having detailed discussions with treating providers. These are done in order to determine the claimant’s functional capacity, any restrictions and limitations, treatment needs and appropriateness, and plans for improving functional ability. The report written is driven by the claim manager’s questions, so as to be maximally useful, concise, and relevant.


A murky picture becomes clearer

Fred’s case was now clear. After Brittany contacted R3 Continuum, R3c assigned a psychologist to conduct the peer review. The psychologist reviewed all of Fred’s records and interviewed Fred and his doctors. In the end, Brittany received a comprehensive report that was concise, written for a non-medical professional, and contained clear opinions and rationale.


Although Fred was physically able to return to work (as was stated by his doctors in the interviews), his behavioral health conditions caused impairment, the report concluded. While Fred remained on leave, the psychologist suggested using that time for more aggressive psychiatric treatments and suggested a plan to help increase functionality. These were discussed with the treatment providers, who were on board with this, and eager to help Fred regain functioning as quickly as possible.


In an ideal setting, Fred would have recovered quickly and returned to work, but that doesn’t always work out, Brittany thought. But the next best thing is to know that once you’ve gone through all of the information, you’ve reached the right conclusion for the claim, and have a path forward.


By using the R3c peer review, your claims staff can feel confident in making accurate and efficient claims decisions, saving time and money, and helping to focus treatment providers on functional improvement and return to work.

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