Chart Review 101
What is chart review?
Chart reviewing varies, but primarily entails reviewing medical necessity or authorizations, and making recommendations. This can be related to length of stay, medications/treatments, procedures, physical therapy or ancillary services, amongst other things.
Who do you work for?
You can work for the insurance company, an Independent Review Organization, or the hospital itself (helping them in the appeals process with insurance companies).
How do you get involved?
You can sign up with a number of companies. If you are very motivated, you can find the names of a lot of the Independent Review Organizations on the National Association of Independent Review Organizations (www.nairo.org/members), and contact them each. Many allow you to apply online. They usually contact you and tell you what they're expecting from you in regards to time and expertise, and you can choose to take it or not. For some companies, the more reviews you do for them, the more that you will get, while others prefer to hire you for formal full time or part time positions.
What kind of experience do I need? Is there training required?
This varies depending on the setting. Hospitals tend to want somebody with more experience. Most require board certification and a license to practice medicine. Some companies want people who are practicing, but not all. There is a certification that you can get through the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP, www.abqaurp.org/default.aspx), which is likely not required, but after you've done over 200 hours of utilization review work, could be worth looking into to make yourself more marketable for the more competitive positions. Some companies ask you to do a formal training (you should ask for compensation for this time).
How do you set your rates?
Pay varies greatly. For some companies you can set your rates and for others they tell you what they offer. It's a supply and demand thing for most, so if companies have a large number of physicians to choose from, they usually aren't willing to pay as much. If it's related to a niche group with a certain expertise, you will be able to charge more. Before accepting or setting the rates, you should consider the amount of time it will take you to do it, as well as the size of the chart. If you want a ballpark, the average seems to be between $100-150/hr.
How much work can you expect to get?
Again, varies greatly depending on their need, your subspecialty, other factors. Some people report barely receiving any while some companies have you commit to a certain number of hours. Some companies will only hire you for a formal full time or part time position. Keep in mind that if you're not hired for a set number of hours, they may not use you very often, and you should view that income as bonus money, rather than something you can count on (much like medical surveys/consulting).
How do you know whether to approve something or not?
They will send you medical records when applicable.
How long do you have to finish the review once it's assigned? What does it involve?
Again, it varies, but I've heard about 48 hours is a typical expected turnaround time. The review may involve reviewing the chart, speaking to the referring clinician, and documenting your findings/recommendations.
Do you have to speak to the referring physician or practitioner? Is this uncomfortable?
Most times, it seems necessary to do a peer-to-peer review with the referring clinician. It can be uncomfortable depending on the interaction!
Do they provide malpractice?
Most companies provide errors and omissions malpractice. If they don't, consider getting a policy. Always make it clear in your recommendations that you haven't seen the patient and that these recommendations are purely based on the information that was provided to you at the time of your assessment.
What are the names of some companies?
Alicare Medical Management
Advanced Medical Reviews
AllMed Healthcare Management, Inc.
BHM Healthcare Solutions
Claims Eval, Inc
Considine & Associates (HealthClaim Review®)
Empire State Medical Scientific and Educational Foundation, Inc.
Healthcare Quality Strategies Inc (HQSI)
IMEDECS (Independent Medical Expert Consulting Services)
KEPRO Physician Reviewers
Lumetra Healthcare Solutions
Managed Medical Review Organization (MMro)
MAXIMUS Federal Services
Medecs Physician Reviewer Opportunities
Medical Consultants Network, LLC
Medical Review Institute of America
Medical ReviewStream by Concentra
MET Healthcare Solutions
MLS Medical Review Services
National Medical Reviews
NEXUS Medical (Associate Member)
Permedion Physician Reviewers
Physician’s Review Organization or Physician's Review Network
Prest & Associates, Inc.
ProPeer Resources Inc
Provider Resources, Inc.
R1 Physician Advisory Services
Reliable Review Services
South Florida Utilization Review
If you have something else that you want to know, please ask, and I'll keep updating this document!