Medical File Reviews and Lifetime Medical Cost Projections

At certain times during the handling of a claim file, the Claims Adjuster needs to organize and sort out complex medical issues in order to make the most appropriate claims decisions. At question could be issues of compensability, causality, excessive treatment, inappropriate treatment, appropriate reserves, the need for further IMEs or Peer Reviews, or simply organizing and making sense of the complex and lengthy medical treatment documented in the file.

This is where our Medical File Review program can be help.

With our program the Adjuster can:

• establish a treatment timeline and identify medical necessity and causality issues
• determine the need for additional areas of inquiry such as expert opinions, case management or auditing intervention
• accurately project lifetime medical (and/or lost wages) costs based upon thorough review of claim file and nationally recognized criteria

A Medical File Review can save the time, effort and expense of setting up IMEs and Peer Reviews in multiple treatment specialties. With the R.N.s recommendations, the most appropriate medical experts can be utilized to address the key issues in the claim.

A Lifetime Medical Cost Projection is an excellent tool for reserving and preparing cases for settlement, and also provides an important baseline from which accurate Medicare Set-Aside allocations can be developed. To come up with a realistic projection, we review all treatment, pharmacy and hospitalization records and billing, as well as nationally recognized guidelines for medical treatment and duration. We provide a detailed, confidential report outlining our findings, itemized projected medical costs and recommendations.