The Medical Claims Review Process – an Overview

The Medical Claims Review Process – an Overview

Medical claims review is an important requirement for both healthcare organizations and health insurers. It helps to ensure that the medical services provided to plan members are appropriate and medically necessary. An efficient review of claims helps prevent insurance fraud and reduce healthcare costs. A medical record review company can provide accurate claim review solutions for healthcare providers as well as health insurers. This is vital to ensure that all items and services billed to Medicare, Medicaid and private payers are medically necessary, properly documented, and coded and billed in keeping with all standards.

What does the medical claims review process involve?

  • The medical record documents are all gathered and organized properly
  • The medical records are sorted and indexed
  • An accurate medical case chronology and timeline are developed for ease of understanding of the various medical events and processes
  • Reference the medical record documents’ tab and identification numbers
  • Reference the claimant
  • Reference the important dates
  • Extract relevant information from each medical record
  • Review the information obtained
  • Tabulate the information from the medical records and present it in an easily comprehensible manner

The first thing that is checked during medical claims processing is whether or not the service is covered under the claimant’s plan. This is called insurance verification or eligibility checking. Any duplicate billings, typos, inaccurate data, and ambiguous entries are all identified, if any. The review helps identify waste, abuse, and insurance fraud.

Apart from being an important step in determining patient eligibility, the medical claim review process helps determine whether the claim has been submitted within the health insurer’s time limit, whether the preauthorization or referral numbers are present as required under the insurer’s policies, and other relevant details. Medical claim review also helps identify whether uncovered services have been billed, concurrent care, bundled codes, and services that are medically necessary.

Insurers and healthcare providers can benefit from associating with a medical record review company that provides dedicated claim review solutions. Such a company has a team of certified coders and medically qualified personnel such as nurses to perform the claims review. Being professionals in the field and knowledgeable in medical procedures and medical terminology, they will review whether the services and items furnished were medically necessary and properly documented, whether the medical claim was correctly coded, submitted and reimbursed.

A medical review company can work with healthcare organizations to review paid claims that may have resulted in an overpayment. Professional claim review can help identify weaknesses if any, that may have led to the overpayment. This will help providers/insurers to address such weaknesses and improve efficiency. You can also request a claims review report that provides a clear summary of the review findings. Large volume medical documentation can be sorted and categorized within the required turnaround time. The review is performed based on the guidelines provided by the American Medical Association (AMA), the National Council on Compensation Insurance (NCCI) and others to ensure compliance.

In case you have found a mistake in the text, please send a message to the author by selecting the mistake and pressing Ctrl-Enter.
Comments (0)

    No comments yet

You must be logged in to comment.

Sign In / Sign Up