Physician's Review Network [PRN] is an independent reviewer of denied medical claims, services, etc. PRN's function is to facilitate NON-PARTISAN reviews of cases that are submitted by insurance companies, at the request of their insured's, for second opinions on medical treatment necessity, appeals, and denials.
The company was founded and [still] owned by Dr. Albert Sheff [a 70 year old retired former penitentiary psychiatrist] and his wife Linda. Dr. Sheff puts forth that PRN offers a medical specialty specific review process that is timely, cost effective, and which factually represents the medical opinion of the physician advisor who is assigned the case.By making this representation PRN and Dr Sheff are perpetuating medical fraud on insurance companies, Attending Physicians, medical claimants, and the public at large.
Often times PRN does indeed facilitate 'clean' case reviews and medical opinion. However, FREQUENTLY Dr. Sheff directs staff members to re-submit already-determined cases to a second physician advisor who is likely to render an opinion [recommendation] more along the lines of his own personal opinions. Dr Sheff is neither qualified nor credentialed to render any medical opinion outside of his Psychiatric specialty, yet he continues to do so.
For example, once a case is returned from the physician advisor it is transcribed and submitted to two levels of QA. Dr. Sheff [and Linda] spends his weekends at the office doing some of the QA himself. Keep in mind Dr. Sheff is NOT the medical Director of PRN, James Gerace, M.D. Is. When Dr. Sheff doesn't like a recommendation, believes a physician advisor approves 'too much, ' or is in some way opposed to the doctor's finding he simply instructs the case processor to find another physician to re-submit the case to; sometimes going so far as to state which reviewer to select. Universally these cases are returned with an opposing recommendation - a recommendation Dr. Sheff agrees with - which is then submitted to the insurance provider as an "Un-Biased, integritious report." At this point, absolutely nothing could be further from the truth.
The trickle down effect impacts the claimant [appealing patient] in such a profound way as to be minimally: unconscionable, and maximally: malpractice.in fact, for PRN's largest client, "MEDVALU, " Dr. Sheff has a clear conflict of interest, sitting on their medical board as an advisor.
Physician advisor audits are occasionally performed [in large part] to determine how many [actual ratios] of recommendations -vs - denials they submit. Too many approvals get the physician 'red flagged' and labeled by Dr. Sheff as liberal, or lazy, or worse: an idiot. Fewer and fewer cases are then submitted to that physician for review.
The Physician Advisors, the employees, and PRN proper are all paid the same fee regardless of how a case is determined. There is no [to my knowledge...] financially vested interest for cases to be resolved one way or another. Other than their regular paychecks, employees do not receive bonuses, incentives, or enticements of any kind to treat any case uniquely or to use any 'preferred' physician advisor. From a non-executive level standpoint all cases are treated equally and ethically.
There are countless medical modalities and treatment methodologies that Dr. Sheff does not agree with. There are actual diagnoses that he believes don't exist. There is insurance contract language he disputes. Dr. Sheff is Board Certified in Psychiatry, hasn't actively practiced medicine in a great number of years, and continually places his medical opinion above those specialty specific physicians that are, this day, actively practicing medicine. Arrogance notwithstanding, his personal medical beliefs are impacting hundreds and hundreds of cases [patients] that might otherwise receive the healthcare they're requesting.
Patients place their trust and faith in a medical system that [by in large] responds appropriately and in their best interests. Because of legally mandated patient advocacy, insurance companies insinuated a mechanism in place for those who seek medical opinion outside the confines of their plans. Legally, morally, and ethically, every person who touches that case [appeal, etc.] should handle it in a manner above reproach. The patient is told to believe in this process, that it is fair, that it is sound, that they can trust. Ultimately though, many, many patients whose claims have come through the doors of Physician's Review Network have been defrauded. Merely at the whim of - and solely at the hand of - Dr. Albert Sheff, their insurance company has denied an appeal that was otherwise decided in their favor. These patients never know the truth and, ultimately, never get the medical care they sought and should have had.
On some level or another, EVERY employee of PRN is aware of Dr Sheff's 'determinations.' I will personally guarantee that PRN executes no contract that states [that] Dr. Sheff [or Linda] reserves the right to personally disagree with medical recommendations then seek out opinions with which he agrees. Nowhere does any contract state [that] PRN will, depending on the diagnosis, condition, treatment, or therapy, submit cases to physicians who'll likely recommend in favor of the insurance company [client] rather than the patient. Finally, nowhere is there a clause which states PRN, et al, shall allow anyone other than a Board Certified, specialty specific physician to review any case or make any recommendation as to the care or claim of a patient for ANY reason whatsoever.in fact, it states just the opposite.
Routinely, cases submitted to PRN for independent medical review are [instead] dependent upon the medical opinions of an aging, non-practicing psychiatrist.in anyone's book this practice of bias clearly constitutes Medical Fraud. Further, from an insurance sub-contracting point of view, this may very well constitute Medical Malpractice.
Patients who are appealing denials for medical treatments, etc; find out who your insurer does independent reviews through. If it's Physician's Review Network - PRN, be afraid - be very afraid!
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