Medical Insurance Review Process

Medical insurance reviews provide results in a timely fashion. Filing a medical claim can be a lengthy process prone to miscommunication and breakdowns in the chain of paperwork. Bringing in an independent review organization can tap into deep reservoirs of medical expertise. The review on this level can determine an objective approval or denial of an insurance claim. The denial will be based on medical fact, however and not on anecdotal evidence.

The Five Key Steps in Medical Insurance Review
The following steps illustrate how a medical claim is reviewed.

• A patient is prescribed a treatment for a condition or injury. The medical opinion of the attending physician along with related charts and information may be submitted or requested in order to request coverage of the insurance claim.

• Medical and physician resources are provided the medical information and asked to review the treatment and prescribed recommendations.

• The medical specialist assigned to the case will provide an unbiased opinion with regard to the treatment.

• An insurance expert reviews the terms of the patient's coverage as offered by the insurance company. They will offer an unbiased determination with regard to whether the patient is covered for the treatment in question.

• Finally, the two opinions are combined to return an objective recommendation for approval or denial.

This process allows for healthcare decisions to be made in a timely and expert fashion. The resource is invaluable for all aspects of the healthcare profession. Patients will receive approval for vital treatment that may be otherwise rejected by a large insurance company that handles its own medical reviews internally and without expert sources.

Anecdotal evidence is never used to deny a claim or pay for an unnecessary treatment. The use of third-party experts and medical specialists provides claim managers with the verification and authentication needed to do not only the right thing, but also the best thing. The medical insurance review process removes the factor of uncertainty that claim managers may face in a world of rising medical costs, complex specialization and treatments.

Avoids Ill-Informed Approvals and Denials

Healthcare costs skyrocket in an atmosphere where a claim manager must err on the side of caution to either pay for unnecessary treatment or deny one that is necessary. Without using an independent review organization, the insurance company may lack the resources to make a decision in a timely fashion.

As illustrated by the five key steps of the review process, experts from both sides of the equation are consulted. Complicated medical technology combined with equally complicated insurance policies and terms can make for a morass of misunderstanding without the right types of expertise. The process also reduces the amount of frustration felt by claim managers, patients and physicians by filtering the claims through the right hands to get the right advice and interpretations.

Fiscal Responsibility

The more approvals of unnecessary treatments, the higher insurance costs will soar. The medical insurance review process allows a claim manager to make an informed decision and eliminate unnecessary treatments. Patients and physicians rely on insurance coverage to underwrite potential treatments for a multitude of conditions.

An insurance expert understands the complex terminology of a coverage policy. Specialized physicians understand the nature of illness and treatment. The combination of expertise improves the process of treatment review and coverage approval. That means no lengthy waits for vital services and no funding for unnecessary ones.

This process has a dramatic impact in reversing the trend of rising healthcare claim costs. By dramatically reducing these riding costs, an insurance company can save money for their consumers, their shareholders and the healthcare community.