Medical Review Companies Role in Your Insurance Claims - Your Health, Your Coverage, Your Guarantee
Medical insurance is often complicated and confusing. The providers and providers that we trust to keep us healthy are constantly changing, or worse still, disappearing completely. Add in 24/7 online tools that make it easy to find deals for the best insurance coverage at the lowest possible price, and you have a perfect storm of confusion. What the medical review companies offer is just what we need: simple quick answers from experts who know their industry inside-out.
In other words, medical review companies provide a layer of trustworthiness on top of an industry that often feels like it’s made up of shady dealings by physicians and healthcare professionals across canada.
What these review companies do is simply provide an extra layer of impartial, third-party validation of the medical bills. It's a service that is perfect for those with chronic conditions or diseases that are so complicated and rare, that they make it difficult to find additional coverage. This can be especially true in auto accident cases, where the injury occurred several years before the claim and it can be challenging to prove what occurred to help with your case.
Whether you are on a pre-existing condition plan, or have been injured in an accident, there is almost always some degree of confusion over what you are entitled to every step of the way. The medical review companies provide a simple way to clarify what you are actually eligible for.
What They Do
Medical Review Companies conduct independent medical reviews of healthcare provider’s clinical records and bills, which can include both in-patient and out-patient services. The goal of these reviews is to reduce the ambiguity around what exactly patients should expect from their health insurance plan. We’ve all had that moment of doubt, when we worried if we were being shortchanged on our insurance coverage, or if our claim was legitimate or not. These companies provide objective third party reviews that help cut through the confusion. They also provide analysis on how relevant the insurance plan is in regards to what they are actually paying for, and whether it was a good deal or not.
What to Look For
A medical review company will work with you and your personal doctor, coordinating schedules and ensuring that the medical reviewer is able to view all relevant clinical records that need to be collected. They will review any clinical notes from previous appointments, phone calls or visits with your specialist. They may review new medical records from your doctor’s office or hospital as well. Each case is unique and there is no standard review process in place. However, common steps include:
1. The medical review company will likely ask you for a copy of your insurance claim, policy and any other documents that relate to your case.
2. The medical review company will then contact your healthcare provider’s office or hospital for all relevant clinical records. These may include notes from previous appointments, phone conversations with specialists, test results and diagnosis. Some healthcare providers are required by law to provide these records, while others may be willing to do so voluntarily.
3. It’s important to note that the medical reviewer is not able to change anything about your case or treatment plan. They are only focused on gathering all the facts so they can make an unbiased determination on what you are entitled to as far as coverage goes.
4. Sometimes you may have additional medical records not included in the original claim for your auto accident insurance, for example if you have taken care of an additional injury directly related to your accident. The medical review company will be able to obtain these as well.
5. The medical reviewer will provide a detailed report on all the findings, recommendations and analysis relating to your case, which they will then send back to your insurance provider.
6. Depending on what is required by law or contract with your insurance provider, the medical review company may require that you attend a meeting with them regarding your case. This is an optional step and many companies do not conduct these meetings as it can be seen as a waste of time and money at some companies or departments. However, it is important to note that these reviews are done completely independently of any third party parties. It’s not up to the medical review company to make or change your claim decisions.
7. If you wish for your medical review company to provide you with a report on what they found, this can be discussed at this meeting with your provider, and can be included in your claim coverage if required.
8. Medical review companies are just one way to verify the legitimacy of an insurance claim or policy. You may also choose to get independent verification from another source, such as an attorney or a financial advisor depending on what type of case you have and how much you could be entitled to under various insurance plans.
9. The medical review company will likely give you a breakdown of your coverage based on the information that they were able to gather. This can help you figure out how much coverage you have for each individual claim, as well as what your total benefits are. They may also be able to provide some additional resources relating to the validity of further claims or treatments.
10. Finally, some medical review companies will even negotiate directly with your insurance provider on your behalf, in an attempt to get more cash compensation for you than what is stated in the original contract.
11. Keep in mind, medical review companies are not attorneys and cannot give legal advice regarding any part of your case or treatment plan. They are not involved in your insurance claim, and they are not able to represent you in any legal matter. If you would like to discuss anything regarding a potential case with an attorney on a free consultation call, visit https://www.baseballinjuries.org/insurance/car-insurance-claim/.
How It Works
1. The medical review company will send out an initial request for records from all parties involved in your case, or if you have already completed this step you can forward them the requested information. They will then contact the appropriate healthcare providers for all the relevant records they need to obtain as well as any other documentation that relates to your accident or injury.
2. Your medical review company will follow up with you on the status of your case and any new findings that they come across.
3. Your medical review company sends out a detailed letter to your insurance provider with all the information they have gathered, including pictures if applicable. The medical review company’s final report can be sent back to you or it may require some more meetings with you and/or your healthcare providers in order to obtain all the relevant clinical information relating to a claim, for example from orthopedic specialist X.
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Conclusion
Medical review companies are paid by insurance companies to verify insurance claims, as well as work with policyholders who may be entitled to more benefits than they have been told by their insurer. Medical review companies follow all applicable laws and regulations when doing their job. It is important to know that you are not in this alone and you will be able to reach out to a medical review company for assistance at any stage of the process. They can help determine if your case meets the criteria for a particular claim, what documents would be required in order for them to verify the case, and which steps can be taken towards filing a further claim or receiving additional compensation if possible.