Impact of the Peer Review Program on Hospitals and Physicians

Abstract

DOI: http://dx.doi.org/10.5915/18-1-11731 Prospective Paymem System DRGs are designed to limit the amount of payment to a hospital for any particular diagnosis, and the Peer Review Organizations are to police hospital activities. In every state, there is a PRO having a contract with the Health Care Financing Administration to perform the following junctions:

(1) Review of reasonableness, necessity, and appropriateness of hospital admissions.
(2) Validation of diagnosis for determination of Medicare reimbursement.
(3) Review of completeness and quality of care provided.
(4) Review of completeness and appropriateness of outlier cases.

Getting a patient admitted to the hospital isn't as easy as it used to be, and it is going to become increasingly difficult. For a physician, it all adds up to another level of interference with which we haven't had to deal before.

The overall PRO program, including preadmission certification and the retrospective review process, is discussed in this article. The focus is on recommendations for physicians of "How to survive under the Prospective Payment System and the PRO program."