Medical record review is an evaluation process that insurers use to determine the medical necessity for a healthcare service or procedure. The review process helps them determine the insurance premiums. A comprehensive analysis of the medical records also reveals any pre-existing health conditions the insurance applicant may have. A pre-existing condition is a medical condition or disease a person already has before taking a health insurance policy. It may be chronic or long-term. This condition could be any health issue – ranging from very serious diseases such as cancer to less serious conditions such as asthma, acne or high blood pressure. Chronic obstructive pulmonary disease (COPD) and sleep apnea are also examples of pre-existing conditions. It could be any chronic physical, mental, or emotional condition for which a person obtained treatment shortly before he or she obtained the health insurance. Health insurers may not be willing to provide insurance coverage to people with pre-existing medical conditions. This is mainly because such people may require medical assistance on a more probable scale and therefore pose more financial risk to the insurer.
Individuals with pre-existing health issues are often requested to undergo a pre-policy medical checkup. It is based on the results of this checkup that the payer determines the premium. In fact, the insurer may even refuse to provide the coverage or reduce the policy coverage, if the results are not favorable. Some payers have a co-payment clause for pre-existing conditions coverage. In this case, the insured person will have to pay a percentage of the claim amount at the time of claim settlement, and the insurer will pay the remaining amount.
Medical Record Review to Find Prior Health Conditions
A pre-existing condition can be identified via medical records review, which would show when, where and what treatment the person had received and what the diagnosis was before he/she enrolled in a new health plan. Typically, the medical records reviewed are
- Emergency room records
- Admission notes
- Nurses’ notes/Triage notes
- Surgery reports
- Pathology reports
- Consultants’ records
- Radiology reports
- Test reports from the lab
- Physical therapy/occupational therapy reports
- Discharge summary
The chart review brings to light any health issues that could have an impact in the long run. The insurer looks for illnesses with long-term side effects and does not consider short-term health issues as pre-existing illnesses. Some insurers would review the applicant’s entire medical history whereas some others may only consider the medical history for a shorter period such as the past three or four years. Health insurers may also have a medical peer review physician analyze the medical records to identify any pre-existing conditions, and to determine medical necessity.
When Are the Medical Records Requested?
The insurer may request a person’s medical history documents during the initial application if he/she informs them about recent illnesses when applying. For example, the payer may want to see the medical records of a person who says that he/she had cancer three years ago and recovered from it. A person’s medical history may affect his or her health insurance costs. The important thing to remember is that the insurer would be considering the possibility of the medical condition returning later in life, and this could make the health plan more expensive. Insurers insist on a medical record review to identify any health issues the applicant may have had in the past and forgot to mention those when applying for life insurance.
Insurers may provide coverage against pre-existing medical conditions by including a waiting period or exclusion for pre-existing health conditions. During this waiting period, the insurance company will not cover the cost of treatments, medicines and doctors’ fees incurred by the applicant for his or her pre-existing medical condition. These expenses will be reimbursed only when the waiting period is over. Nevertheless, the health plan will continue to cover any expenses that are incurred because of other illnesses that are covered under the policy.
Important Uses of Medical Record Review
- A medical records review helps an insurer ascertain that a person has a pre-existing condition and there is more probability of a claim. So, even if they provide coverage, they may charge a higher premium for it. The findings from the review may be used to deny the claim as well.
- Accurate reviews also help understand whether the claimant is exaggerating a prior injury or illness to try and get more compensation.
- Through a detailed review of the medical records, the insurer can identify declinable pre-existing conditions that may be uninsurable. These include severe obesity, severe mental disorders, congestive heart failure, HIV/AIDS, and so on.
The terms and conditions related to coverage of pre-existing medical conditions differ from on health plan to another. The claimant’s medical history unveiled via a chart review has a significant impact on his/her health insurance costs. As mentioned earlier, those with high-risk health conditions and pre-existing health conditions will find that their policy is more expensive. Health insurers utilize the services of a medical review company to have the medical records organized properly and reviewed on time so that the core medical facts are available. The medical data is presented in an easily comprehensible format, which makes it easier for the health insurer to arrive at the right coverage decision.