Medical claims review is performed to ascertain that the medical claims submitted by healthcare providers to insurers are accurate, and appropriate for the services provided to patients. The clinical review of medical records by a medical record review team or a medical peer review team helps ensure that payment is made only for covered services, and those services that meet medical necessity and coding requirements.
The medical documentation available is thoroughly reviewed and an expert review report is prepared for easy perusal and understanding. For insurers and their attorneys, these reports provide valuable information regarding usage of drugs and devices, and proof of injury.
Professional Medical Review Solutions and Their Advantages
The services of a professional medical review company are useful to attorneys assisting health insurers, especially when mass tort cases are involved. Such cases are filed in large volumes and attorneys may find it quite challenging to choose cases that are more likely to win over those that do not have enough supporting evidence.
Through a proper review of the medical documentation available, an expert medical review team can easily identify strong and weak cases and make it easier for the attorney to make a choice.
What does the claim review process involve?
- When a medical claim is processed, the first thing that is typically checked is whether or not the service is covered under the patient’s plan.
- The initial review would also ensure that there are no duplicate billings, confusing entries, typos, or inaccurate data.
- A professional company would perform Medicare policy compliance review (CFRs, LCDs, NCDs, IOM & SSA).
- The review would also help identify fraud, waste, abuse, and beneficiary harm as well as evaluate the consistency of contractor in interpretation of policy/potential policy issues.
Let us consider the advantages of having medical records- and medical claims review done by an experienced medical claims review company.
- A comprehensive review of the medical claims is made, medical claim audits are performed, and the review helps determine medical necessity, appropriateness of services, and the efficiency of the treatments provided to patients.
- Eligible, ineligible, and would-be eligible cases are categorized from a medical viewpoint.
- The review of claims is done based on the guidelines provided by the AMA (American Medical Association), NCCI (National Council on Compensation Insurance) and others.
- Large volume records can be sorted or categorized in less amount of time and money.
- Eligible cases are separated from ineligible cases and the efforts and resources spent on ineligible case are saved.
- Timely management helps meet all deadlines.
A detailed review of medical records and claims involves a point-to-point analysis of the relationship of the product/drug usage and injuries, which will also cover prior medical or surgical history, ambiguities if any, and other complications. A detailed chronology of medical events will also be included. The claims are checked for medical necessity as well, to ensure that the services provided
- Are proper and necessary for the diagnosis or treatment of the claimant’s medical condition.
- Meet the standards of good medical practice in the local area and are not chiefly for the convenience of the treating physician(s) or the claimant.
- Are provided for the diagnosis, direct care, and treatment of the claimant’s medical condition.
Health plans may use a medical peer review to determine whether or not to uphold a claim denial. In this case, the review is performed by a healthcare specialist belonging to the same field as the original medical claim. The review of medical claims and medical records is thus a very important process to make sure that insurance payments are made only to deserving claimants and prevent insurance fraud.
It also helps determine whether the claim has been submitted within the insurer’s time limit, whether pre-authorization/referral numbers are present as required by the particular payer, and other important details. Importantly, a dedicated medical claim review by a professional medical review company exposes non-covered services that have been billed, concurrent care, invalid codes, bundled codes, and medically unnecessary services.
