National Review of Peer Review Organizations

This final audit report points out that the Health Care Financing Administration (HCFA) has developed many effective tools for monitoring the performance of peer review organizations (PROs). However, further improvements could be made if HCFA took action to (1) ensure that all PRO recommended financial adjustments are made; (2) ensure that PROs identify unnecessary impatient admissions and ambulatory surgeries, medical code validation errors, and quality of care problems; (3) ensure that PRO reviewers are adequately trained and allocated sufficient time to complete reviews; (4) consider not allowing PRO review coordinators the authority to override medical screen failures without a physician's review; and (5) issue regulations giving PROs the authority to deny payment for substandard quality of care.