Why Managing Medical Records Is Key to Successful Third-party Claims

by | Published on Feb 3, 2023 | Medical Record Review

Medical record organization and management is key to ensuring a successful third-party claim. Third-party health insurance includes public as well as private insurance programs, and managed care and preferred provider networks. Third party insurance companies that are required to provide coverage to the injured person are faced with the need to review all the relevant medical records so that the validity of the claim can be understood. To speed up claims processing and reduce the complexity involved, insurers, insurance attorneys, law firms, and adjusters utilize medical review service provided by experienced medical review firms.

Medical Record Organization and Review – A Key Process

Why it is important to have a well-organized set of medical records? To have an accurate and complete analysis of medical treatments received by a claimant, high quality data capture is vital. If data capture is to be efficient and accurate, the medical records need to be in the correct chronological order. However, the records that arrive following a medical record request related to third-party claims are usually voluminous and unorganized. Other major concerns with medical records are inconsistencies, wrong medical codes, lack of required details, information totally missing from the records, ambiguities, and medical jargon. These make medical record organization and review quite challenging for entities outside the medical field and with limited knowledge of medicine.

So, how can one address these issues? An experienced medical review service provider can assist in this regard, organizing the medical records and extracting key data effectively and accurately. You can also request for concise medical record summaries that contain all the necessary data in an easily understandable format. Medical records management involves processes such as

  • Medical records indexing – Filing and organizing the documents
  • Medical case chronology or timeline – Arranging the medical records in chronological order
  • Medical record review – Comprehensive review of the records to understand the various medical facts
  • Medical record summary preparation – Creating concise and accurate summaries based on the details available in the medical records.

The above processes are performed with strict adherence to HIPAA mandates.

A properly performed review of the medical records is helpful for insurance underwriters also. It enables identification of risk factors such as alcohol/drug abuse, personal history of conditions such as heart disease and cancer, family medical history, and prior claims for injuries/disabilities.

What aspects are focused on during a medical chart review?

  • Whether there is an accurate statement/record of the claimant’s physical problems, treatment plan and objectives, and unbiased information regarding the claimant’s response to the treatment and care provided
  • Whether the criteria for third-party coverage is satisfied and clear in succinct and accurate medical record documentation
  • Whether prescriptions, medical reason for the treatment provided, treatment outcome, a feasible discharge plan, management of medical services, instructions given to the claimant/family members, adaptation or discontinuance of medical services when required, are all documented clearly
  • Whether the medical bills are properly coded
  • Whether there is any inappropriate billing issues such as upcoding, balance billing, unbundling and so on
  • Whether there are inflated ambulatory surgery center bills
  • Whether there are unverified or unmanaged medical bills
  • Whether there are missing medical bills or just reports and procedures
  • Whether there are clearly identifiable physician signature(s)

How Medical Record Analysis and Management Speeds Up Claims Settlement

  • First of all, the insurance adjuster, attorney can work better with organized medical records and claim documents. This, along with a summarized Table of Contents makes the reference and review process easy. This, in turn helps with efficient claims negotiation and settlement and an overall reliable health insurance process.
  • Proper medical records analysis and management helps to establish medical necessity for the various treatment choices such as diagnostic studies, medications, therapy and so on. The insurer can approve or deny the claim based on the review of the relevant medical data.
  • Organized medical records make it easy to access information about all the medical services the claimant has received and ensure that the diagnosis and procedure codes are accurately documented and identified.

Advantages of Working with a Reliable Medical Review Service

  • Gain access to the services of an expert team that can ensure increased medical records accuracy, improved speed, and increased productivity
  • Customized medical record organization and indexing
  • Cost savings because there is no need to hire medical review staff
  • Increased security for sensitive claimant data through round-the-clock data safeguard, data backup, and regular cyber hygiene procedures
  • Quick, customized turnaround time
  • Multilevel quality check to ensure clean and accurate medical information

The value of accurate medical records and proper medical records management for efficient third-party claim settlement cannot be overstated. Present day medical record review companies utilize the best technologies including artificial intelligence to make their processes more efficient and quicker. The focus is on streamlining the healthcare claims processing workflow for their clients, ensuring easy and unhindered access to the medical documentation. Since the review and validation of the medical documentation can be done quickly, claims processing also becomes accurate, quick and efficient.

Discover our medical record review solutions and partner with us for your next case.

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