Why Is Medical Record Review Important For Insurance Companies?

by | Published on Mar 28, 2022 | Medical Record Review

As an evaluation process to determine medical necessity for a healthcare service or procedure, medical record review is very important for insurance companies. Insurers also need to review the medical records when determining premiums for the healthcare coverage of insurance applicants. These premiums may vary based on the health conditions of the applicant. The process involves a detailed analysis of the medical records of the claimant – admission notes, physicians’ notes, nursing notes, correspondence between healthcare providers, diagnostic tests, monitoring equipment printouts and so on. Apart from its medical significance, medical record analysis has legal importance as well.

Given that insurance investigators and claims handlers may not be familiar with the complex medical jargon and healthcare needs of their plan members, the support of a medical record review company may become essential for insurers. The organization, interpretation, analysis, and summarization of the medical data is ideally performed by professionals who have good knowledge of medicine and the required experience to review the records.

The medical records to be reviewed include the following.

  • ER records
  • Nurses’ notes/Triage notes
  • Admission notes
  • Operative notes
  • Consultants’ records
  • Pathology reports
  • Radiology reports
  • Laboratory test reports
  • Occupational therapy/physical therapy reports
  • Discharge summary

So, how are medical records and their review significant for a health insurer?

  • To verify information on insurance applications: Before issuing a policy, an insurance company may require the applicant to undergo a medical exam and/or submit their medical records. The data in the records is used to substantiate the details provided in the application. Besides, the record review also reveals any pre-existing medical conditions of the applicant, family medical history and other details required that could have a bearing on the coverage amount and premium.
  • To calculate the value of insurance claims: Medical record analysis is vital to understand the extent and severity of a disability claimant’s condition. This will help the insurer decide the value of a claim. Typically, claimants who cannot work due to a disabling injury need to prove that the injury or condition is grave. If this cannot be established via a medical record review, the claim may be minimized or even denied. Insurance adjusters may also review the medical records periodically to show that the claimant is no longer disabled. In such cases, they will discontinue the benefits.

A claimant’s medical history is revealed through a comprehensive review of his/her medical records. This medical history could have an impact on their insurance costs. Those with high-risk health conditions or pre-existing conditions will find that their policy is quite expensive. Thus, medical record organization and review provided by an experienced medical record review company are great support solutions for insurance companies. Once the required medical records are retrieved from various healthcare providers, they are quickly and efficiently reviewed to extract the core medical facts. These significant findings are presented in the form of an easy-to-understand summary. Insurers have the advantage of working with a service provider that has the necessary record review expertise, excellent medical knowledge, and an extensive understanding of health insurance providers and their specific requirements.

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