A Guide to Building a Robust Medical Review Team



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Constructing a solid medical review team requires the successful networking, staffing, management, and ongoing support of the clinicians and the support team.

The Significance of a Solid Team

Medical review is the clinical review of medical records and supporting data in order to provide claims determinations and ensure that payment is made only for services that meet all coding, coverage, and medical necessity guidelines and requirements. Each year, billions of dollars are lost to fraud, waste, and abuse in the health care industry. Improper payments, scams, and overbilling are just a few of the contributing factors, and reasons why a strong medical review team is an integral part of reducing financial losses. As a result of the medical review team’s findings, in conjunction with the contribution of the Compliance Specialists, Investigators, Data Analysts, and Statisticians, financial recoveries are obtained from a wide array of health care providers and organizations.

Determining Your Needs: What Skills & Experience Are Necessary?

When staffing a medical review team, the right credentials, clinical experience, and passion for health care are critical components to look for in candidates. It is necessary for clinicians to have extensive knowledge of state and federal healthcare regulations, coverage guidelines, policies, and reimbursement rules in order to perform medical review successfully. In addition, they must possess substantial knowledge and proven ability to continually assesses and evaluate clinical compliance with relevant regulations. Clinicians who have a working knowledge of applying coding guidelines including Current Procedural Terminology (CPT) codes, Clinical Modification (ICD-10-CM) codes, and Healthcare Common Procedure Coding System (HCPCS) codes are also among the top qualified as they are more familiar with coding when they perform their review. Medical review subject matter experts typically have a wide-variety of service areas and clinical topics expertise, and good reasoning ability in order to define problems, collect data, establish facts, and draw valid conclusions. A complete medical review team consists of Physicians, Registered Nurses, and Certified Coders — each having a wide-variety of experience with diverse service areas and clinical topics.

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Sourcing the Talent & Building a Network

It can be difficult for some clinicians to leave a position providing direct patient care and transition to a new, behind-the-scenes career as a reviewer. Although medical review is a very different type of role, many clinicians believe it is an opportunity to use their expertise to give back by preventing fraud and protecting the future of the Federal dollars of the Medicare and Medicaid system.  In addition, a solid network of clinicians is an essential piece of a successful medical review team. Building good relationships with physicians, nurses, and coders of a wide variety of specialties and remaining in contact with this network is important to ensure there are specialties readily available for when the opportunity presents itself. Providing exceptional customer service and treating this network of candidates with respect and professionalism will ensure these candidates continue to stay interested in joining the team, and ready to meet the needs of the client.

IntegrityM’s Strategic Staffing Solutions

The demand for healthcare staffing will continue to rapidly increase, and a reliable partner is needed to deliver the most qualified Nurse Reviewers, clinicians, Compliance Specialists, Investigators, Data Analysts, and Subject Matter Experts. Integrity Management Services’ Strategic Staffing Solutions is a quality-focused staffing resolution with a wide variety of disciplines. We deliver the expertise you need to thrive in today’s dynamic industry.

For additional information on how we can enhance your team, call us at 703-683-9600 or contact us online.



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