We are independent & ad-supported. We may earn a commission for purchases made through our links.
Advertiser Disclosure
Our website is an independent, advertising-supported platform. We provide our content free of charge to our readers, and to keep it that way, we rely on revenue generated through advertisements and affiliate partnerships. This means that when you click on certain links on our site and make a purchase, we may earn a commission. Learn more.
How We Make Money
We sustain our operations through affiliate commissions and advertising. If you click on an affiliate link and make a purchase, we may receive a commission from the merchant at no additional cost to you. We also display advertisements on our website, which help generate revenue to support our work and keep our content free for readers. Our editorial team operates independently of our advertising and affiliate partnerships to ensure that our content remains unbiased and focused on providing you with the best information and recommendations based on thorough research and honest evaluations. To remain transparent, we’ve provided a list of our current affiliate partners here.

What is a Medical Record Review?

Karyn Maier
Updated Mar 03, 2024
Our promise to you
The Health Board is dedicated to creating trustworthy, high-quality content that always prioritizes transparency, integrity, and inclusivity above all else. Our ensure that our content creation and review process includes rigorous fact-checking, evidence-based, and continual updates to ensure accuracy and reliability.

Our Promise to you

Founded in 2002, our company has been a trusted resource for readers seeking informative and engaging content. Our dedication to quality remains unwavering—and will never change. We follow a strict editorial policy, ensuring that our content is authored by highly qualified professionals and edited by subject matter experts. This guarantees that everything we publish is objective, accurate, and trustworthy.

Over the years, we've refined our approach to cover a wide range of topics, providing readers with reliable and practical advice to enhance their knowledge and skills. That's why millions of readers turn to us each year. Join us in celebrating the joy of learning, guided by standards you can trust.

Editorial Standards

At The Health Board, we are committed to creating content that you can trust. Our editorial process is designed to ensure that every piece of content we publish is accurate, reliable, and informative.

Our team of experienced writers and editors follows a strict set of guidelines to ensure the highest quality content. We conduct thorough research, fact-check all information, and rely on credible sources to back up our claims. Our content is reviewed by subject-matter experts to ensure accuracy and clarity.

We believe in transparency and maintain editorial independence from our advertisers. Our team does not receive direct compensation from advertisers, allowing us to create unbiased content that prioritizes your interests.

A medical record review is a formal examination of patient data and personal medical records for the purpose of validating a diagnosis, settling billing disputes, or to facilitate paying a health insurance claim. It may also be performed to investigate legal implications stemming from sustaining an injury from medical services obtained. The most common reason for reviewing medical records, however, is to determine the need for certain medical procedures. In fact, health insurance companies frequently launch a complete utilization review (UR) in response to a claim submitted for coverage of a medical procedure. Which procedures are likely to provoke a review vary depending on the insured’s policy, but some of the most common are alternative therapies, home care services, infertility treatments, organ transplants, prosthetic devices, and services related to pre-existing conditions.

It should be noted that there is a protocol for conducting a medical record review for utilization purposes by insurance companies. Specifically, this type of review is an evaluation of the need for medical equipment or services that have already been delivered or administered. Utilization management, on the other hand, refers to pre-authorization of equipment or services. This is significant because it means that an insurance company can potentially deny coverage for services rendered but deemed unnecessary, leaving the patient stuck with the cost in full. People who have received notice of an impending review from their insurance company or a subsequent notice of “adverse determination” should know that the denial of any claim is subject to an appeals process that is governed by law.

Another common reason for requesting a medical record review is for litigation purposes. In fact, attorneys who specialize in personal injury or malpractice law often consult third-party medical experts to review all hospital and physician records, as well as depositions and affidavits relevant to the case. Sometimes, this third-party is obtained to draft an opinion letter comparing services and treatments provided to the accepted standards of care, which may be used to initiate settlement proceedings or to provoke formal action from the medical malpractice board. In some cases, the consultant will serve as an expert witness through trial testimony.

Individuals may also request a review to help them to better understand and evaluate the course of treatment undertaken to date and how to proceed going forward. This type of service is usually offered by specialty clinics and facilities, such as those providing services related to infertility, cancer, or substance abuse and recovery. In addition to helping the patient stay on the right therapeutic track, this practice also lends itself to an investigation of new information and procedures applicable to the patient’s specific condition.

The Health Board is dedicated to providing accurate and trustworthy information. We carefully select reputable sources and employ a rigorous fact-checking process to maintain the highest standards. To learn more about our commitment to accuracy, read our editorial process.
Karyn Maier
By Karyn Maier
Contributing articles to The Health Board is just one of Karyn Maier's many professional pursuits. Based in New York's Catskill Mountain region, Karyn is also a magazine writer, columnist, and author of four books. She specializes in topics related to green living and botanical medicine, drawing from her extensive knowledge to create informative and engaging content for readers.
Discussion Comments
By anon177764 — On May 19, 2011

what about conducting medical record reviews for academic purposes?

By anon143725 — On Jan 17, 2011

The only thing I don't like about chart reviews, is that 70 percent of the time, reps that come into offices to perform a chart-review of numerous patient-records don't know the program they are using. This gives them access to patients' information.

The reps print off records or scan records into their own laptop for insurance use, yes, but they have access to records that they really shouldn't. There needs to be more trustworthy individuals retrieving this information when doing on-site chart reviews.

Karyn Maier
Karyn Maier
Contributing articles to The Health Board is just one of Karyn Maier's many professional pursuits. Based in New York's...
Learn more
The Health Board, in your inbox

Our latest articles, guides, and more, delivered daily.

The Health Board, in your inbox

Our latest articles, guides, and more, delivered daily.