View source for Definition:Peer review

🔎 '''Peer review''' in insurance refers to a structured evaluation process in which a qualified professional — typically a physician, [[Definition:Actuary | actuary]], [[Definition:Underwriting | underwriter]], or engineer — assesses another professional's work product, opinion, or decision to ensure accuracy, consistency, and adherence to established standards. The term appears most frequently in two distinct insurance contexts: medical peer review within [[Definition:Health insurance | health]], [[Definition:Workers' compensation insurance | workers' compensation]], and [[Definition:Disability insurance | disability]] claims, and technical or actuarial peer review within [[Definition:Insurance carrier | carrier]] operations and regulatory filings.

⚙️ In the [[Definition:Claims management | claims]] arena, medical peer review involves an independent physician evaluating treatment plans, medical necessity determinations, or [[Definition:Independent medical examination (IME) | independent medical examination]] findings to confirm that recommended care aligns with evidence-based guidelines. [[Definition:Claims adjuster | Adjusters]] request peer reviews when a [[Definition:Claim | claim]] involves disputed medical treatment, prolonged disability, or high-cost procedures — the reviewing physician's opinion helps the carrier make informed [[Definition:Coverage determination | coverage decisions]] and manage [[Definition:Loss reserve | reserves]]. On the actuarial side, peer review is a professional obligation: the [[Definition:Actuarial Standards Board | Actuarial Standards Board]] requires that [[Definition:Actuarial opinion | actuarial opinions]] — particularly those filed with regulators, such as [[Definition:Statement of actuarial opinion | statements of actuarial opinion]] on loss reserves — undergo review by a qualified actuary who was not involved in preparing the original work.

🏛️ Both forms of peer review serve as critical quality-control and governance mechanisms. Medical peer review helps insurers defend [[Definition:Claim denial | claim denials]] against regulatory challenges and [[Definition:Bad faith | bad faith]] allegations by demonstrating that decisions were grounded in clinical evidence rather than arbitrary cost-cutting. Actuarial peer review strengthens the credibility of financial statements and regulatory filings, reducing the risk of [[Definition:Reserve deficiency | reserve deficiencies]] going undetected. Regulators and [[Definition:Rating agency | rating agencies]] view robust peer-review practices as indicators of sound [[Definition:Corporate governance | governance]], and carriers that skimp on them expose themselves to both financial surprises and reputational damage.

'''Related concepts'''
{{Div col|colwidth=20em}}
* [[Definition:Independent medical examination (IME)]]
* [[Definition:Actuarial opinion]]
* [[Definition:Medical necessity]]
* [[Definition:Claims management]]
* [[Definition:Utilization review]]
* [[Definition:Actuarial Standards Board]]
{{Div col end}}