Primaris Physician Reviewer Fact Sheet

Physician Reviewer Fact Sheet
Why serve as a physician reviewer?
• Endorsed by Primaris’ board of directors.
• Professionally and personally rewarding.
• Skills learned while reviewing medical records
have added value to delivery of patient care.
• Review cases within the comfort of your own
home or office. All necessary materials are mailed
to you with no direct patient contact.
• Our nurses and non-physician reviewers provide
support as you review the case.
• Primaris’ liability insurance protects every physician
reviewer.
What are the types of physician review panels?
Standard Medicare Panel
• Beneficiary complaints
• Quality of care concerns
• Potential EMTALA (patient dumping) violations
• Discharge appeals
• Utilization/DRG billing matters
• Reviewers are offered cases testing the best
of their clinical and review skills
• Requires extensive documentation of
the PR’s professional opinion
• Cases are handled on an individualized
basis and may require expert legal
testimony or deposition
Private Consultancy Panel
• Provides peer review for private insurance
companies and self-insured employers
regarding utilization and quality
of care concerns
• Reviews are separate from the
Medicare QIO contract
What is the process?
1) Case is screened by a non-physician reviewer (e.g. registered nurse).
2) If unable to approve a record, PR provides medical opinion and makes a decision.
3) No adverse determination is rendered without review by PR.
4) For Medicare appeal cases: PR is expected to make an attempt to speak with the attending
physician to get information before making a decision.
5) PR completes and returns reviews to Primaris within 7 calendar days of receiving the case.
Note: Some cases, such as EMTALA reviews and discharge appeals, require a 24 hour turn-around
by the PR.
MO-13-01-CR Feb 2013 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for
Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.

Physician Reviewer Fact Sheet
Is there any training required?
New reviewers are required to complete PR clinical review training which is available on the
Primaris website. To access the training and obtain 3.0 hours AMA PRA Category 1 CME credit,
visit www.primaris.org/training. You’ll need a user account to complete the training - to apply for
one, send your name, email, telephone and city to online@primaris.org.
How do I start?
Complete the application and provide:
• Copy of your current, unrestricted Missouri medical license
• Copy of your current Missouri BNDD certificate
• Copy of your current DEA certificate
• Verification of board certification/eligibility
• Current Curriculum Vitae (CV)
• Confidentiality/conflict of interest statement
• IRS Form W-9
Questions?
Contact Sharon Hoffarth, MD, MPH, FACPM
Medical Director of Primaris
shoffarth@primaris.org
1-800-735-6776 ext. 170
MO-13-01-CR Feb 2013 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with
the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do
not necessarily reflect CMS policy.