A medical record review is a formal examination of patient data and personal medical records for the purpose of validating a diagnosis, settling billing disputes, or to facilitate paying a health insurance claim. It may also be performed to investigate legal implications stemming from sustaining an injury from medical services obtained. The most common reason for reviewing medical records, however, is to determine the need for certain medical procedures. In fact, health insurance companies frequently launch a complete utilization review (UR) in response to a claim submitted for coverage of a medical procedure. Which procedures are likely to provoke a review vary depending on the insured’s policy, but some of the most common are alternative therapies, home care services, infertility treatments, organ transplants, prosthetic devices, and services related to pre-existing conditions.
It should be noted that there is a protocol for conducting a medical record review for utilization purposes by insurance companies. Specifically, this type of review is an evaluation of the need for medical equipment or services that have already been delivered or administered. Utilization management, on the other hand, refers to pre-authorization of equipment or services. This is significant because it means that an insurance company can potentially deny coverage for services rendered but deemed unnecessary, leaving the patient stuck with the cost in full. People who have received notice of an impending review from their insurance company or a subsequent notice of “adverse determination” should know that the denial of any claim is subject to an appeals process that is governed by law.
Another common reason for requesting a medical record review is for litigation purposes. In fact, attorneys who specialize in personal injury or malpractice law often consult third-party medical experts to review all hospital and physician records, as well as depositions and affidavits relevant to the case. Sometimes, this third-party is obtained to draft an opinion letter comparing services and treatments provided to the accepted standards of care, which may be used to initiate settlement proceedings or to provoke formal action from the medical malpractice board. In some cases, the consultant will serve as an expert witness through trial testimony.
Individuals may also request a review to help them to better understand and evaluate the course of treatment undertaken to date and how to proceed going forward. This type of service is usually offered by specialty clinics and facilities, such as those providing services related to infertility, cancer, or substance abuse and recovery. In addition to helping the patient stay on the right therapeutic track, this practice also lends itself to an investigation of new information and procedures applicable to the patient’s specific condition.