Establishing Medical Necessity via Medical Chart Review

My name is Jessica and I am a Solutions Manager from Managed Outsource Solutions. Today I am here to talk to you about establishing medical necessity via medical chart review.

Please check out our website for the infographic.

00:17 Importance of medical record review

Misrepresenting treatments is one of the most common forms of health insurance frauds.  When treatments that are not covered as medically necessary are misrepresented, it makes medical record review a very important consideration. When evaluating a patient’s health record, a medical record review company would scrutinize all visits, including telemedicine encounters, especially physical therapy and chiropractic services. Medical record review helps ensure that the patient received the right treatment for his/her particular health condition. Such review can help attorneys identify manipulations in the claim that suggest possible fraud.

01:01 Role of medical chart review in proving medical necessity

Claiming for medically unnecessary treatments leads to increase in the overall cost of hospitalization. A comprehensive medical chart review would clearly identify the patient and whether he or she is being provided the care identified on each chart entry, and ensure that all entries are legible and dated, and complete.

Please check out the infographic below on the website

Establishing medical necessity via medical chart review

01:33 What does the reviewer looks for in medical records?

During medical records review, the reviewer looks for:

• Official notes that support the level of service billed
• The patient’s history that shows that the DME prescribed is medically necessary
• Billing for phantom visits or non-existent physician visits
• Diagnostic studies referrals are medically necessary and there is documentation to support the same
• Whether the DME is compatible with the coded and billed items

02:05 What documents are reviewed?

Medical record review for attorneys include review of the diverse documents such as:

• ED records
• Admission records
• History and physical
• Discharge summary
• Operative notes
• Pathology reports and
• Consulting physician reports, and more

Thank you for listening! We hope you have a wonderful day!