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Medical chart reviews are a major step in the lifecycle of personal injury, workers' compensation, and medical malpractice lawsuits. These reviews help determine the legitimacy of the claim and extent of injury or illness. The medical chart review process is often completed by a physician or other healthcare professional, but it can be done independently with the help of an expert.

There are different types of medical charts that can be reviewed depending on what information is needed for litigation purposes.

Chart review for Medical Necessity Determinations

This type of medical chart review is requested to determine whether a patient had been seen by the physician before an injury or illness. Medical charts serve as a record of the patient’s history, containing information about diseases or injuries, growth milestones, and more. Health insurers often use this type of review to evaluate the appropriateness and cost-effectiveness of care. Utilizing pre-authorization reviews is the most common way to determine medical necessity. Hospitals use a qualified physician to review unexpected services that are not covered under the member's plan or if they think there is something medically wrong with the patient. The difference between the reviews done by insurance companies and hospitals is that the reviews performed by the latter are not directly related to payment for services.

Chart Review for Legal Purposes

When evidence of medical malpractice and injury is needed, judges and juries often require an expert’s opinion to show that the care or treatments were appropriate. These reviews are typically conducted by a medical review team hired by the plaintiff or defense lawyer. The team reviews all the relevant records and other documentation, and work with an expert to prepare a statement about what care was provided.

Chart Review for Workers’ Compensation And Disability Claims

Workers injured at job sites or on the job would be entitled to coverage for medical care and disability payments. Although their claims have to be evaluated and the claim approved by the insurance company.  Medical chart reviews, in this case, are often conducted to evaluate the injury or illness and what care is needed.  This review is typically conducted by a physician and will inform the court on how the worker's injuries affect their ability to work and offer an estimate of recovery time. When an employee has a job injury, the insurance company decides whether it is valid or not and if so, who will evaluate them. The causality of an injury must be clearly stated in order to determine if the claim is valid.

Chart Review for Clinical Documentation and Coding

This type of medical chart review focuses on the clinical documentation and coding aspect. The physician will set out to answer questions related to billing codes, diagnosis, treatments, procedures prescribed or performed for the patient, as well as diagnostic tests ordered. This information is then translated into a readable format that attorneys can use in litigation proceedings.

Chart Review for Insurance Underwriting

Insurance companies need to know two things: the average life expectancy, and how likely people are to die from different kinds of medical problems. Businesses need to know how many years a person is expected to live in order to calculate life insurance premiums.

Medical Research-Related Chart Review

Medical records can be reviewed for litigation or research purposes.  This type of review is often done in a lab setting with the help of a physician.

Review of the Medical Chart for Quality Management

Chart review is important for healthcare systems to gather data before making any changes. It is a regular process done to determine the quality of healthcare delivered and identify areas for improvement.

Ending Note

Medical chart reviews are carried out to get an unbiased evaluation of the medical case, which is done by professionals with training. Medical chart reviews are a vital component of personal injury, workers' compensation, or medical malpractice lawsuits. The medical chart is a document that serves both as an accounting of care and a valuable tool for litigation support.


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