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Chart review can refer to many different opportunities where you review medical documentation and provide related expertise, including determination of medical necessity (often referred to as utilization review/management), expert witness work, reviewing workman’s compensation or disability claims, underwriting for insurance policies, clinical documentation and coding, and for collaborating oversight of other members of the healthcare team. The companies hiring these physicians are looking for physicians who are readily accessible, as many of these decisions are time sensitive. They often also want language proficiency to write a clear report.
This usually involves working for a utilization management company, a healthcare system, or an insurance company. These physicians review orders for things like procedures, treatments, or other healthcare services and determine whether they feel they are medically indicated and/or necessary. It is a popular nonclinical option in that it pays reasonably well, and can offer a full transition from clinical work.
UM jobs are usually offered as part time or full time jobs with set hourly requirements, although there are also some unique arrangements such as weekend only jobs. Significant flexibility in your schedule may be present compared to other non-clinical jobs, as you may just have to commit to the number of hours rather than the timing of the hours. Your employer may be the insurance company itself, the hospital performing services, or a third party company contracted by the payor. Most positions are remote, although occasionally some of these positions have a physical office you are asked to work out of. You are usually given a list of cases to review, and you go through them in order. While you may occasionally get interrupted by emails or phone calls, most of the time you are uninterrupted. Most reviews only take a few minutes, though occasionally a more thorough investigation is necessary. The number of reviews and calls can change from day to day and are likely different amongst the different companies depending on the number of things they require prior authorizations for and what they tend to deny. Many physicians wonder if there are incentives for denying care, though we haven’t seen admission of this on the groups.
Many cases will involve reviewing prior authorizations for planned or requested procedures, or reviewing utilization while in the hospital in real time (“concurrent reviews”). Concurrent reviews usually involve reviewing aspects of the patient’s hospital stay such as whether the level of care chosen is appropriate (ICU versus floor bed), length of stay, and whether continued hospitalization is necessary or whether the patient can be discharged or moved to a less urgent setting. If you are employed directly by the hospital instead of the payor, your job will be to reconcile the treatment plans with the patient’s insurance policy and hopefully prevent payments from being denied.
Many physicians have mixed feelings about this type of work as they worry about being on the other side of the prior authorization phone call with a physician colleague and denying a desired order. Your job as the UM physician is to try and take an unbiased approach as to whether the requested service is indicated, free of the bias of things like what a patient is asking for and free from the pressure of being too busy clinically to look up best practice guidelines. Most companies require board certification and practice experience which will help you as you go through best practice guidelines and relevant research and apply the collective knowledge to determining whether a prior authorization or payment request makes sense. You will also have to have a knowledge of the payor’s policies and know whether the service is covered by the patient’s specific insurance policy. Unfortunately, this means you may agree with the referring clinician that a procedure is indicated, but have to state that nonetheless, it is not covered by the patient’s insurance policy.
Part of your job may also involve reviewing the insurance company’s policies and revising them as necessary, which could give you the ability to help your colleagues get appropriate treatment approved. Additionally, there are peer review/quality control measures in place at several companies to ensure most people are on the same page about what should be denied or not.
You can find out more about chart review as well as how to find these jobs on our Chart Review 101 page.
The National Association of Independent Review Organizations (NAIRO) also contains more information about Chart Review, as well as a list of many Independent Review Organizations that you may be interested in working for.
We have an entire page on expert witness work and finding opportunities. Learn more here.
Insurance Company Underwriting Jobs
What is insurance medicine, and where do physicians fit in?
This is typically working within life, disability, and health insurance companies. There are several roles you can take on as a physician/medical director:
Analyze medically complex applicant medical records to answer questions submitted by underwriters for insurability risk. They’ll ask you to assess morbidity and mortality risks for the life and disability products.
Assist with life and disability claims
Read and interpret EKGs and stress tests (you don’t actually do the exams)
Trainer for non-physician insurance underwriters
Product development and marketing (no insurance sales)
What skills do you need?
Breadth of knowledge of various disease states across systems (most are within internal medicine subspecialties)
The ability to interpret EKGs for life insurance applications
They will often train you on life expectancy estimation and risk assessment
Often require a certification in Insurance medicine (Diplomate in Insurance Medicine) - there is a Board which does oral and written examinations.
Often need to have been practicing medicine (residency trained, board certified, at least 5 years of clinical experience generally desired)
What kinds of opportunities exist?
Limited openings for full time positions, which usually require the Diplomate
Occasional or contractual part time opportunities for practicing clinicians
How do you find these positions?
Word of mouth and networking
Executive search/recruiting or LinkedIn
What salary can you expect to make?
Salary is contingent on experience, but could range between $175,000 and $300,000.
Disability, Worker’s Comp & Auto Claims
While these jobs are more often called “file review” rather than “chart review,” the principles are similar. In these jobs, you review a patient’s medical record from the viewpoint of the injury of history as well as the duties of the patient’s job or responsibilities to determine whether the patient’s request for compensation makes sense. Since the patient is treated by their own physician most times and the health insurance company is not the one requesting the review, the questions are not usually about the necessity of treatment, but rather about determining to what, if any, extent that the patient’s injury precludes them from performing their duties at work.
While a physician is not always involved in this process, the less straightforward and the more significant a claim is monetarily, the more likely a physician will be called in to review given how high the stakes are. If someone is determined disabled, the amount of money that could have to be paid out on an annual basis can be quite large, so insurance companies are willing to put a lot of time and money into this assessment. If a claim is not straightforward or requires a complicated assessment of the extent of injury or disability, a physician will often be asked to review the case. This may sometimes require an in person independent medical examination (IME) in addition to the remote review of the chart. They may be asked to opine on the severity of the injury, expected prognosis and course of recovery, whether a patient can return to work, and also causality of the patient’s injury and whether it was due to the most recent injury or a more chronic condition/prior injury. Rarely, a physician may be asked to testify in relevant litigation.
This work is generally more flexible than traditional utilization management jobs, in that it is less time sensitive and can be done on nights and weekends. The physician can set an hourly rate (varies greatly, and we’ve seen physicians on the group citing anywhere between $75-300/hour; this is all negotiable depending on your unique expertise and skillset). There are also full time positions available. Typically, most work is remote and you will receive an electronic file from the company along with specific questions that need to be answered. However, having to perform IMEs or testify may come with an in person component. In general, you will require board certification (this is sometimes even legally required). You may or may not need to be actively practicing.
CDI & Coding/Physician Advisor
You can be hired as a physician (typically by hospital systems or by companies that help hospitals with these issues) to help optimize billing and coding by reviewing chart documentation to decrease the likelihood of denials. Of note, these positions are often filled by nurses, but larger systems may hire physicians to review more complicated cases, especially if they require communication with physicians to effectively communicate what needs to be changed.
Medical Directorships or Collaborating Physician
As the use of non-physician healthcare practitioners increases in different settings, there is often a regulatory or practical need for quality assurance, second opinions, or chart review by physicians. For example, laboratories, medical spas, and telemedicine companies often require periodic review of the care being delivered. Physician roles may include signing off on reports/documentation, examining data to suggest changes to policies/procedures, or giving second opinions on complex cases. While companies or practitioners asking for physician help in these tasks often suggest that the work is minimal, physicians should understand that there is liability associated with having others practice under their oversight, and that their license or financials could be at risk if something goes wrong. While many agreements often only involve reviewing a percentage of cases, the remainder of the cases performed by the collaborating entity or non-physician practitioner may also fall under their “supervision” and carry liability risk as well. Therefore, physicians should approach these roles with caution, and if they decide to engage, having clear expectations and roles spelled out and agreed to in a written contract is very important.