Medical Chart Reviewers
Medical chart reviewers used the state-of-the-art tools offered via computerized recognitions systems in combination with trained professionals that can spot unusual medical records results in order to set them aside for further examination. Depending on the set of medical records that are going to be reviewed, the trends analysis will identify specific incidences when the medical records does not meet the average outcome or parameters of a case that is a similar type. This is called exceptions analysis and by thorough research of the case files that have such qualities, some underlying apparent reasoning may be applied, in that the exception cases note when the system has a breakdown or that the protocols applied did not meet the needs requirements of a particular case. Not every case is so organized to have the positive results from standards application practices, but if a case is extraordinary in its needs requirements or in its results determination, it need to be analyzed further to make sure this only an anomaly that is a rare occurrence and is not a system-wide failure especi9ally in non-responsive behavior to cases that may present themselves over and over again.
It is important that the computer analysis is enhanced with the seasoned experience and in-depth understanding of a specialist practitioner. The computer analysis can only achieve a certain average of results predictions, but is not prepared to offer solutions to human-based interface with the patient clients. This is the purview of the analytic practitioner, to determine and make recommendations based on review of the medical records data. For large payment system such as state or federal agencies whether they be Medicare, Medicaid (or Medi-Cal in California), medical chart reviewers are highly skilled in reviewing the medical records for validation of the claims under these state wide and federal run programs.
Of course in an y federal or state program utilization is a key component of the analysis. Utilization is not only helping to ensure that any clinic locations are operating at their highest level of efficiency, but also to ensure that the quality of care received meets or exceeds the protocol requirements. This focus of the medical chart reviewers is on determining not only the areas that are possible for cost containment, but also the areas where the quality of patient care can be improved.
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