Health insurance companies handle many types of claims including personal injury, medical malpractice, mass tort, product liability and others. When processing the claims submitted, insurers look for medical necessity. They reimburse the claim only if they are sure the treatments are medically necessary and appropriate for the patient. This is determined via a comprehensive medical record analysis by a professional company. The insurer may ask for a medical peer review if they find any discrepancy or anomaly in the claim. When it comes to insurance claims and associated legal disputes, both insurance peer review and medical record review are crucial for attorneys. These processes have distinct purposes and may have a significant impact on the outcome of the case.
Medical Record Review vs. Medical Peer Review for Insurance
In a medical record review, the patient’s medical records are examined in great detail. In the insurance sector, this review process is conducted in connection with claims processing, legal disputes and medical necessity determination. For attorneys, this review process helps gather the evidence they need to build a case.
The entire medical history of the patient including the diagnoses, treatments provided, progress of the patient and outcomes is evaluated. It provides a clear picture of the patient’s medical journey and the various patterns or discrepancies in the care provided. In addition, attorneys can establish accurate timelines, and substantiate claims or defenses. An important use of a record review is that it serves as a foundation for expert witness testimony in court, wherein expert witnesses explain complex medical facts to juries and judges.
What does the medical documentation review involve?
The first step is the request for the records by the attorney from healthcare providers who are the custodians. Once the records are obtained, they are organized properly to understand the timeline. Then, staff at a medical review company or a qualified medical professional, or the attorney’s legal team examines the records to extract critical facts and identify potential legal issues. The final step is the preparation of the review report that contains the findings from the records, which are used to develop an appropriate legal strategy.
Now, let us look at the insurance peer review process.
Here, a qualified medical professional reviews the medical necessity, appropriateness and quality of care provided to a patient. Typically, the review is requested by insurance companies when reviewing the medical claims submitted to them. It is performed by a physician who has expertise in the particular medical specialty. The review is done based on established medical guidelines and best practices.
The main concern here is to evaluate the medical necessity of the treatment provided and whether it was provided in line with accepted standards. For insurers, peer reviews are a strategy to control costs and make sure they are not reimbursing for unnecessary medical procedures. The findings from a peer review helps payors determine whether to approve or deny the claim. If a claim is denied, the next steps are appeals and further legal processes.
What does medical peer review for insurance involve?
The first step here is claim submission by a healthcare provider to the concerned insurance company. If the insurer feels further analysis is required, they would initiate a peer review. A qualified and experienced physician belonging to the specific medical specialty is selected. This reviewer evaluates the medical records, treatment protocols and relevant medical guidelines. Once the review is over, the peer review physician prepares a report either recommending approval of the claim or its denial based on his study.
Useful for Both Attorneys and Insurers
Attorneys and insurance companies that need insurance peer review or medical record analysis can hire a reliable medical review company for these processes. Both processes are important in the healthcare as well as legal sectors. Attorneys who leverage these, benefit from more favorable case outcomes. The review helps them understand the case or claim very well and navigate the complexities with confidence and efficiently. Insurers can ensure that they are paying only for medically necessary treatments. Proper peer review helps payors to control healthcare costs and prevent insurance fraud to a great extent.