Medical Chart Review – What is in it?
A medical chart is a record of protected health information (PHI) collected and stored chronologically from the time we are born. The admission, discharge, and transfer (ADT) protocol with a medical record number (MRN) assigned to it is the backbone of a medical records management system.
Medical Chart Review involves a systematic examination and evaluation of an individual’s comprehensive medical record. This process ensures a comprehensive overview of an individual’s healthcare history, with the ADT protocol and MRN serving as foundational elements.
There are different types of medical chart review designed for various needs. Let us have a quick look at them.
Review for Medical Necessity
As the name suggests, a review for medical necessity validates the physician’s recommendation on why he or she chose a specific treatment method. Physicians place a request for authorization (RFA) to the insurance provider for approval of a treatment choice such as medications, therapy, or a diagnostic study that he or she deems necessary to identify the disease accurately and for future advanced treatments. The insurance company reserves the right to approve or deny the request based on the review of pertinent medical data.
Review for Medical-Legal Collaboration
Attorneys and physicians have little in common and they may not understand each other’s language. However, they need to collaborate when a medico-legal case involves pay-outs. A patient’s attorney looks to the doctor to simplify the patient’s case to fight an insurance claim against denial of a certain brand-name drug, diagnostic procedures such as an MRI or PET scan, or outpatient or inpatient procedures.
Here’s where an in-depth medical chart review service helps. A team of professionals with expertise in summarization usually executes it. This summary of reliable data arranged chronologically acts as a handy reference to assist the attorney during a legal proceeding.
Review for Worker’s Compensation or Employee Benefits
The employer pays a premium to cushion the impact of unfortunate medical expenses of an employee arising out of employment (AOE) or during the course of employment (COE).
The Workers Comp board assists patients to financially sustain themselves during treatment through cash benefits and reimbursements. The board even funds programs to cross-train an employee to a different job profile if the injury does not allow the worker to resume duty in the present capacity.
On occasion, when the insurer insists on third-party review, the legal team hires Independent Medical Examiners (IMEs) such as an Agreed Medical Evaluator (AME) or a Qualified Medical Examiner (QME) to rule out any medical negligence and specifically validate the claim made by the employee.
AI medical records review done through this process results in the determination of the employee’s work status and compensation for medical costs incurred.
Review for Coding and Billing
Medical records review is also done for coding and billing purposes. The International Classification of Diseases (ICD) database allocates hundreds of thousands of medical codes for various disease conditions and diagnostic studies (ICD 11 is currently in use).
Reviewing medical records for coding requires exceptional technical know-how in coding modalities, medical terminology, and bookkeeping. Coding errors may result in significant costs for the employer or the insurer.
Review for Insurance Underwriting
Insurance agencies typically conduct extensive medical records reviews. These reviews aim to identify risk factors like drug abuse, alcohol abuse, personal history of ailments (such as heart disease and cancer), family medical history, and details of previous claims for injuries and disabilities.
Since many insurance companies do not have enough time to conduct extensive reviews of the medical records, they outsource these tasks to gain time-sensitive insights while remaining cost effective.
Review for Research
Independent investigators and researchers involved in pharmaceutical advancement do a thorough medical record analysis to understand patient behavior after treatment. They analyze how the patient reacts to a specific drug or technique. Additionally, they observe the response to medication, including side effects and aftereffects.
These data help to modify the treatment course including changes in prescription dosage, diagnostic tools such as scopes, or to chart a new method of treatment.
Review for Medical Audit
Chart review for a medical audit is a vital process for healthcare systems to evaluate treatment outcomes and patient satisfaction. A medical audit covers such items as checking all numerical values, medications, dosages, frequency, vital signs, lab values, cancer stages, allergies, diagnosis, impression, assessment, etc., involving the patient’s health.
Hospitals often make policy changes to improve patient care based on medical audit results and analysis. The data generated through this process can be applied more generally to prevent medical malpractices from plaguing the healthcare system.
Streamline Medical Chart Reviews With PreludeSys
Medical chart review services are integral to the organization of medical records, providing accurate details of events affecting a patient’s health status from various sources. The Health Insurance Portability and Accountability Act (HIPAA) ensures the protection and privacy of these highly confidential records.
At PreludeSys, we meticulously focus on the quality of the summaries we deliver. We extract pertinent information from vast datasets, ensuring accuracy and relevance. Our prime focus is on preventing data breaches by adhering strictly to patient confidentiality protocols.
Contact PreludeSys today for professional medical record review services tailored to your business needs. Experience value-based services where quality is our benchmark.
