Peer Review: Impact of a System Based on Billing Claims

Abstract

To determine whether adjustment of billing claims made by a peer-review mechanism affects subsequent practice patterns, we examined the records of the San Joaquin Foundation for Medical Care for services rendered Medi-Cal patients. For 13 of 15 procedures studied (six types of injections, six types of physician visits and three laboratory tests), a statistically significant relation was found between the percentage of billing claims adjusted by the peer-review process and subsequent changes in practice patterns as measured by decreases in the rate of change in the monthly number (i.e., the regression-line slopes) of these services claimed. The magnitude and consistency of these relations, however, were not uniform for all procedures, indicating a need for ongoing monitoring of the review process to allocate review resources effectively. (N Engl J Med 291: 877–883, 1974)