A medical claim or bill that healthcare providers submit to a patient’s insurance company contains unique medical codes that describe the care provided to the patient. Whether it is a diagnosis, a procedure, medications/medical supplies, medical equipment, or medical transportation – all these services the healthcare provider uses to provide patient care are described on the medical claim using relevant medical codes. Insurers perform a medical claim review to understand the claimant’s health concern, the services provided to address the concern, and determine what reimbursement is due to the provider. Medical claims are unique in that each claim contains facts that are specific to each patient and his/her medical encounters.
Why Perform a Claim Review?
Insurance companies review medical claims to determine liability and the reimbursement due for various services. Claim review is also necessary to determine the eligibility of the beneficiary; that the benefit is covered or not payable under another policy; that the service was medically necessary; that the service was of good quality, and that the charges are reasonable.
A health insurer may use an attorney’s service to review the policy claims and ensure that the claim is legally valid, and that the charges claimed are fair. Also, insurers use legal counsel to defend themselves against fraudulent claims. An attorney helps a healthcare insurer in the following ways:
- The attorney reviews the validity of the insurance claim
- They review the claims to ensure that it meets the insurer’s coverage requirements.
- A thorough review of the claims, mostly performed with the support of a medical review company reveals whether the claim is genuine or falsified.
- Insurance attorneys also defend insurance companies during litigation.
The Important Role of a Medical Review Service
A medical review service assisting insurance defense attorneys helps identify errors through a medical claim review. The information obtained via an accurate review can be used to provide proper health insurance payments and also recover improper payments in case the claim was already paid.
Information contained in a medical claim file can be found under two heads, Claim Header and Claim Detail.
- The former contains a summary of the most relevant information in the medical claim or PHI (Protected Health Information) such as the patient’s name, date of birth, gender, zip code. Other details include the NPI or National Provider Identifier for the attending physician and the healthcare facility providing the service, inpatient procedure (if applicable), primary diagnosis code, name of the patient’s insurance provider, DRG or Diagnosis-related group, and overall charge for the claim.
- Under Claim Detail, the information included are date of service, procedure code, corresponding diagnosis code, attending physician’s NPI number, NDC or National Drug Code (if applicable), and charge for the service.
A medical review service provider can help attorneys speed up claims processing by reviewing the medical records of the claimant and determining if the medical claim submitted to the insurer is a valid one.
- Their review report would identify the claimant, identification number, important dates such as date of incident or injury, dates of services provided and so on.
- Complete information that is relevant to the claim is obtained from each medical record and classified appropriately.
- The extracted information is reviewed to ensure accuracy.
- The information is tabulated and presented in an easy-to-understand format.
- A medical case chronology and summary are prepared that the attorney would find very useful when studying the claim.
When claim review is done by an experienced provider, attorneys get important information such as patient eligibility and whether the claim has been submitted within the insurance company’s set time limit. Other information includes the following:
- Whether preauthorization / referral numbers are included as required by the health plan
- Whether non-covered services have been billed
- Whether medically unnecessary services have been provided
- Bundled medical codes
- Concurrent care
Reliable medical review services help insurers and their attorneys ensure compliance, reduce costs, and enhance overall value through verification of accurate benefits administration, proper claims coding, and adherence to applicable guidelines. Speedy review of claims is ensured via a knowledgeable, dedicated workforce and advanced technology. Apart from that, accuracy is ensured through a stringent quality control process.
Accurate claims review is the practical way for health insurers to make sure that they are not paying for services that never happened. They get to benefit from cost savings because payment is not made for duplicate or medically unnecessary procedures. Thus, insurers, their attorneys, and medical review companies assisting attorneys can work together to enhance healthcare, root out false claims, and reduce healthcare costs.
