In any personal injury claims, the insurance companies pay the victim for the damages they endured as a result of the negligence of their insured. Insurance companies will often be involved in personal injury claims regardless of the circumstances, faults, and injuries and expeditiously resolve the claim.

When an occurrence is covered by an insurance policy and a claim is made, an insurance adjuster is tasked with looking into what happened and determining the claim's value.

The adjuster will subsequently be able to estimate the probable financial obligation of the insurance provider to its insured once the investigation is over. It is important to note that the aim of the adjusters will be to reduce the worth of the claim and convince the claimant to accept less money than their claim is worth.

• Evidence supporting your claim and the fault of their policyholder
• Your injuries' nature, extent, and long-term prognosis
• They may use inconsistencies against you, such as the fact that you delayed seeking medical attention.
• Medical history that exposes previous wounds or illnesses
• This blog would sail through medical record investigation of insurance companies and medical record reviewing.

Why would an insurance company investigate an injury claim?

The main objective of the adjuster is to determine if the damage amount you requested was reasonable. Finding evidence that they can utilize in the negotiation talks is their second objective. The claimant hiring a lawyer so they can set up an independent investigation while the insurance company looks into your claim.

In order to compensate the injured party as little as possible, insurance firms look into claims. They'll utilize all the data they gather during an investigation to win the case in court or to negotiate a lesser settlement.

Insurance Claims and Medical Records

To determine whether a personal injury claim is valid, the insurance company would examine the claimant’s medical records. When submitting a claim, you might have already supplied certain medical documentation.

They can ask for it if they can't locate enough evidence to support the degree of the claimant’s injury. The adjuster would conduct a thorough investigation of all the medical records and request for more records if needed.

Medical documents are considered strong evidence in any injury claim and hence adjusters pay particular attention to it. To make sure that the claims they pay out are valid, they have a stake in challenging everything and examining the supporting documentation. Any assertions the claimant and the injury lawyer make without providing backing could make the adjuster worry whether your claim is being padded or even inflated.

You are free to choose whether or not to disclose your medical records. If you don't disclose, the adjuster can say there isn't enough evidence to support your claim. However, make careful to review your medical records before handing them over. Find out from your attorney which documents to share and which to keep to yourself.

The insurance adjuster will want access to any records pertaining to your injuries and medical care as your personal injury case develops, and in some circumstances, you might be required to submit to an "independent medical examination" (IME).

Medical Record Review for Insurance Companies

As discussed above, medical records serve as crucial evidence for an insurance company to investigate a personal injury claim. However, to go through the bulky medical records and finding out the medical information pertaining to the subject case is an arduous task for the insurance companies.

How only the vital medical record data is picked out and used in injury investigation?

It is done by the process of analysing the medical records and capturing only the necessary medical data pertaining to the claim, called medical record review.

Examining medical necessity or authorizations and making suggestions are also part of chart reviewing. This may have to do with the amount of time spent there, medications or other treatments, procedures, physical therapy, or other services, among other things.

Insurance companies use a process called underwriting to gather data about applicants and assess the risk involved in granting them a policy. Insurance companies can determine a potential applicant's propensity to file claims by reviewing their medical history. In deciding whether to charge for coverage and how much it would cost, this is helpful.

Insurance adjusters may routinely analyse the medical data to show that the claimant is no longer disabled. They will discontinue offering the benefits in this case.

What is the main focus of medical record review in insurance claims?

An insurance company may ask the applicant to have a medical exam and/or disclose their medical records before issuing a policy in order to confirm the information on the application. The data from the records is used to back up the data from the application.

The evaluation of the applicant's data also reveals crucial details that might influence the coverage and cost.

While reviewing medical records for an insurance claim, the following elements should be focussed.

• General health condition of the claimant.
• Prior medical incidents of the claimant, and pre-existing conditions.
• Details of the treatment and medications given to the claimant.
• Cost of the treatment given to the patient and the reasonability of the bills.
• Contradictions in the statements given by the claimant (if any).
• Missing data in the medical records.

In order to stop paying benefits, adjusters must also examine medical records for any changes that would indicate that the claimant is no longer disabled.

Steps in Medical Record Review

To calculate the price of insurance claims: Analyzing medical records is necessary to determine the extent and severity of a disability claimant's illness. This will make it easier for the insurer to estimate the claim's value. Applicants who are unable to work due to a crippling injury typically need to provide proof of how bad their condition is. If this cannot be demonstrated through a review of the medical records, the claim may be reduced or even refused.

• Retrieval of medical records
• Sorting and organizing records
• Analysis and interpretation of data
• Making a patient chronology or timeline
• Summarizing the medical record
• Finding the missing data

Electronic medical records serve as a representation of the thorough medical history that has been compiled on a person since birth (EMRs). These records are obtained from the hospitals and thoroughly checked for accuracy and any missing linkages before the review process begins.

These records have been separated into categories to distinguish claim-related materials in order to speed up assessment. The DNP (date, page number, and provider) exercise is then utilized to determine which documents will be used for case-specific analysis.

Challenges in Medical Record Review Process

Reviewing complicated medical records with thousands of pages and huge volume of necessary and irrelevant data is not an easy task. Medical records would contain medical terminologies that is to be understood and analysed during the review process.

The reviewer should be well-versed on these terminologies to understand the medical conditions, their causes, complications, and their effects. This would in turn reflect in the value of the insurance claim given by the company.

Another challenge in reviewing and analyzing medical charts is analyzing the handwritten notes in the medical records. It is the responsibility of the medical chart reviewer to interpret the notes accurately without assuming and misinterpreting it. Misinterpretation of the handwritten notes may represent something wholly unrelated to the original aim.

Outsourcing Medical Record Reviews

Outsourcing medical record review to an expert review outsourcing team would result in precise and crisp medical chart review reports. Medical record review offshoring companies would hold a strong team with expertise.

Legal nurse consultants, physicians, legal and paralegal experts in outsourcing companies would easily crack the hefty medical records for the insurance claims without missing out any vital data. Proper sorting and cherry-picking the crucial information would strongly help the claim.

Another advantage of outsourcing review is reduced Turn Around Time (TAT) of the review process. When medico-legal experts conduct the review, the time taken would be less when compared to an insurance company doing the same process. With less TAT, the insurance companies can obtain an accurate medical chart review and proceed with the claiming process.

Medical record review when done by adept medical record reviewers would help the insurance team understand the strength and weakness of the subject claim.

Outsourcing medical record review to a skilled medical record review company would take care of the injury case and result in a detailed review report strong enough to substantiate the claim.