When you’re injured in an accident in San Antonio, getting proper medical care should be your primary concern. Unfortunately, insurance companies often employ tactics to minimize their financial responsibilities, and one powerful method they use is the “peer review” process. This strategy can significantly impact your ability to receive necessary medical treatments.

What Is a Peer Review in Personal Injury Claims?

A peer review occurs when an insurance company hires a doctor to review your medical records and evaluate whether the treatments recommended by your physician are medically necessary. While this sounds reasonable in theory, the reality often differs significantly from the stated purpose.

These reviews are conducted without the reviewer ever examining you in person. Instead, the insurance company’s chosen doctor simply reviews documentation and makes determinations that can profoundly affect your recovery.

The True Purpose Behind Insurance Peer Reviews

Insurance companies are for-profit entities with financial incentives to minimize payouts. Peer reviews serve as a powerful tool to achieve this goal by providing seemingly objective medical opinions that support claim denials.

The peer review process allows insurance companies to:

• Challenge the medical necessity of treatments
• Question the relatedness of injuries to the accident
• Dispute the duration or extent of required care
• Create documentary evidence supporting reduced settlements

Common Tactics Used in Peer Reviews After San Antonio Accidents

1. Selective Reviewer Selection

Insurance companies tend to use the same reviewers repeatedly—physicians who have established patterns of opinion that favor the insurer. These doctors may receive substantial income from conducting peer reviews, creating a financial incentive to provide opinions that satisfy the insurance company.

2. Incomplete Medical Record Review

Reviewers often work with incomplete medical files. The insurance company might selectively provide only certain records, omitting crucial information that supports the necessity of treatment. This selective presentation creates a skewed foundation for the reviewer’s opinion.

3. Misapplication of Treatment Guidelines

Peer reviewers frequently cite medical guidelines in rigid ways that fail to account for individual patient circumstances. They may apply workers’ compensation guidelines to auto accident cases or use outdated standards that don’t reflect current medical best practices.

4. Emphasizing Pre-existing Conditions

A common tactic is attributing your current symptoms to pre-existing conditions rather than the accident. Even if you had no symptoms before the collision, reviewers might claim that imaging findings (like disc bulges or arthritic changes) indicate your pain stems from natural degeneration rather than trauma.

The Impact on San Antonio Accident Victims

When an insurance company denies treatment based on a peer review, the consequences for accident victims can be severe:

Financial Burden

When insurers deny claims for necessary medical treatment, patients often face difficult choices:

• Pay out-of-pocket for treatment
• Use health insurance (with high deductibles and co-pays)
• Forego recommended treatments entirely
• Take on medical debt

Delayed Recovery

Interruptions in treatment can significantly impair recovery. Continuity of care is essential in many rehabilitation programs, and denials can break this continuity at critical junctures in your healing process.

Pressure to Accept Lower Settlements

Treatment denials often precede settlement offers. When facing mounting medical bills and without access to necessary care, many accident victims feel pressured to accept inadequate settlements out of financial necessity.

Medical Treatments Commonly Targeted by Peer Reviews

Certain treatments are more frequently subjected to peer review denial in San Antonio accident cases:

Physical Therapy Beyond Initial Sessions

While insurance companies often approve initial physical therapy evaluations and a few sessions, they frequently deny extended treatment plans through peer reviews, claiming additional sessions aren’t medically necessary despite ongoing pain.

Diagnostic Imaging

MRIs, CT scans, and other advanced imaging are frequently denied through peer reviews, with reviewers claiming these tests won’t change treatment plans despite their importance in identifying serious injuries.

Pain Management Treatments

Interventional procedures like epidural steroid injections, medial branch blocks, and radiofrequency ablations are common targets for denial, with reviewers suggesting more conservative treatments despite their failure to provide relief.

Surgical Consultations and Procedures

Peer reviewers often claim that surgery is not indicated despite specialist recommendations, leaving patients in pain and without access to potentially beneficial procedures.

Fighting Back Against Unjust Peer Review Denials

If you’re facing treatment denials based on peer reviews, there are several strategies to challenge these decisions:

Understand Texas Insurance Regulations

Texas insurance law provides certain protections against unreasonable claim denials. The Texas Insurance Code prohibits unfair claim settlement practices, which can include unreasonable denial of treatments based on biased peer reviews.

Document Everything

Keep detailed records of:

• All communications with the insurance company
• Medical recommendations from your treating physicians
• Pain levels and how limitations affect your daily life
• Any deterioration following treatment denials

Request Internal Reviews

Insurance companies have appeal processes for denied claims. Your treating physician can provide additional documentation and medical literature supporting the necessity of the recommended treatment.

Consider Independent Medical Examinations

An independent medical examination (IME) from a respected specialist can counter a negative peer review. Unlike the insurance company’s paper review, an IME involves an actual physical examination and comprehensive evaluation.

Consult with a San Antonio Personal Injury Attorney

An experienced personal injury attorney can:

• Challenge biased peer reviews
• Obtain the reviewer’s credentials and history of working with insurers
• Depose peer reviewers in litigation to expose biases
• Negotiate with insurers from a position of strength
• File bad faith claims when appropriate

Legal Strategies That Combat Peer Review Tactics

Experienced San Antonio personal injury attorneys employ several effective strategies to counter peer review denials:

Investigating Reviewer Backgrounds

Skilled attorneys research peer reviewers’ credentials, publication history, and relationships with insurance companies. Many reviewers earn substantial portions of their income from insurance companies, creating conflicts of interest that can be exposed during litigation.

Deposing Peer Reviewers

In litigation, attorneys can depose peer reviewers under oath, asking pointed questions about:

• How many reviews they perform annually for insurance companies
• What percentage of reviews result in denial recommendations
• Their income from peer review work
• Whether they examined the patient personally
• What specific medical literature supports their opinions

Utilizing Treating Physician Testimony

Courts and juries often give greater weight to the opinions of physicians who have actually examined and treated the patient. Your attorney can emphasize the relationship between you and your treating doctors versus the insurance company’s paper reviewer.

Filing Bad Faith Claims When Appropriate

When insurance companies systematically deny valid claims through biased peer reviews, they may be liable for bad faith insurance practices. These claims can result in additional damages beyond the original claim amount, creating leverage for fair settlements.

Protecting Yourself After a San Antonio Accident

To protect your right to necessary medical care after an accident:

Seek Treatment Promptly

Delays in treatment can be used against you in peer reviews, with reviewers claiming that if you were truly injured, you would have sought immediate care.

Follow Medical Advice Consistently

Attend all appointments and follow treatment recommendations. Gaps in treatment create openings for peer reviewers to claim you weren’t seriously injured or that treatments weren’t helping.

Be Thorough When Describing Symptoms

Make sure your medical providers document all symptoms and limitations. Complete and accurate medical records are crucial when challenging negative peer reviews.

Consult an Attorney Early

An experienced San Antonio personal injury attorney can guide you through the claims process, recommend trusted medical providers, and address peer review issues before they result in denials.

Conclusion

Insurance peer reviews represent a significant hurdle for many San Antonio accident victims seeking necessary medical care. By understanding how this process works and the tactics employed by insurance companies, you can better protect your right to appropriate treatment and fair compensation.

If you’re facing treatment denials based on peer reviews after an accident, remember that these opinions are not final determinations. With proper legal representation and medical documentation, you can challenge biased reviews and fight for the care you need to recover.

The path to recovery shouldn’t be obstructed by insurance tactics designed to protect profits rather than patients. By working with experienced professionals who understand these strategies, you can level the playing field and focus on what matters most—your health and recovery after a San Antonio accident.