What are the Different Types of Medical Chart Reviews?

17 March 2022

Medical chart – 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 record management system. 

There are different types of medical chart reviews 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 records review helps. It is usually executed by a team of professionals with expertise in summarization. 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.

A medical record review done through this process results in the determination of the employee’s work status and compensation of medical costs incurred.

Review for Coding and Billing

Medical records review is also done for coding and billing purposes. Hundreds of thousands of medical codes in the International Classification of Diseases (ICD) database are allocated for various disease conditions and diagnostic studies (ICD 11 is in vogue)

Medical records review for a coding objective demands exceptional technical know-how of coding modalities, medical terminology, and bookkeeping as coding errors may result in large costs for the employer or the insurer. 

Review for Insurance Underwriting

Every insurance agency usually performs an extensive medical records review to identify risk factors such as 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 with a specific drug or a technique and observe the response to medication, including side effects and aftereffects. 

 These data are used 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. 


Medical chart reviews are an integral part of the organization of medical records. The records collected from different sources provide accurate details of events that affect the patient’s health status. These records are highly confidential and are governed by the by Health Insurance Portability and Accountability Act (HIPAA) to protect privacy.

At PreludeSys, we focus intently on the quality of the summary we deliver to the client. Furthermore, we leave no stone unturned to abstract correct and relevant information from vast amounts of data. Our prime focus is to avoid data breaches, and we pay special attention to patient confidentiality and protocols.

Contact our team at PreludeSys for professional medical record review services to suit your business requirements. Our services are value based with quality as the benchmark.

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