A company that does medical reviews does more than just give a second opinion. The fact that a medical review company is fair is important not only for the bottom line but also for the end result. Too often, patients think they are just numbers in a file or pieces of information in a computer programme. People are unhappy and frustrated because they think insurance companies automatically deny claims without really understanding what the patient needs.
What's it got to do with you?
Patients are people, and when they need health care, they don't want to read the fine print or a medical dictionary. They just want their claims paid. Most of the time, they won't know that their insurance claim went through the medical insurance review process of an Insurance Review Organization. In fact, they probably only have to fill out the forms, give their insurance card to the receptionist, and sign the necessary release forms.
One of the most common complaints about needing health care is how expensive it is, followed by how hard it is to deal with all the paperwork that comes with it. An insurance review organisation is a middle company that insurance companies can send their claims to in order to find out if a claim made by a person insured by their company is valid from a medical and insurance coverage point of view.
Your health is important.
People often think that insurance companies that turn down a claim are heartless or care more about making money than they do about helping people. This idea is only made worse when an insurance company denies a claim because of a lack of evidence. When a claim goes through the insurance review process at a medical review company, it won't be turned down or approved based on anecdotal evidence.
For example, one person has shoulder, back, and neck pain, as well as eczema and bra strap grooves. Her medical history shows that she has been to a chiropractor for years and been told to take non-steroidal anti-inflammatory drugs (like Tylenol and Advil). She has also worn special support bras to help her 34DD frame, but none of this has helped. Many of the symptoms the woman's medical history pointed to can be caused by breasts that are too big.
The doctor suggested that she have a breast reduction to fix the problem and get rid of the symptoms.
Your insurance is important.
When the claim is sent to the insurance company, it's possible that the policy won't cover procedures that aren't medically necessary. Many policies do not. Claim managers who don't know much about medicine will often compare a procedure request to a list of procedures that have already been approved. If cosmetic procedures aren't covered, the claim will probably be turned down. The patient has to decide whether to pay for the surgery out of pocket or keep suffering.
The answer will be different if the claim is sent to a third party, like a medical review company. A lot of doctors and insurance experts are available to the medical review company. The doctors' recommendations and the patient's medical history will be looked at by the medical specialists. When the third-party specialist looks at her file, they will look at her history of shoulder, neck, and back pain. They will keep track of the visits to the chiropractor and any other symptoms that are important.
If the medical specialist agrees with the patient's doctor that the patient has Macromastia (excessively large breasts), then he or she will know that breast reduction surgery is the best way to help the patient feel better.
Confidence is important.
Patients whose insurance company uses a medical review company may not know how the review process works, but the effect is big. Their insurance costs will probably go down. Their health needs will be taken care of. They won't have to pay more for health care because they paid for unnecessary procedures. When it comes down to it, a medical review company gives patients confidence that their medical and insurance needs will be met. They won't have to be miserable for no reason or deal with debt collectors.
