Case Review

A case review, in the medical world, is the review of a patients care history to ensure that the treatment provided meets Medical Necessity Criteria, and is the optimum course of treatment for that particular patient and their situation.

Cases are typically reviewed by a Physician Advisor, a peer to the Physician providing care.  The advisor will determine if the care administered is appropriate considering the context.

Case Review is important for reimbursement and authorization purposes.  Whenever you receive care the Physician wants to ensure that they will be reimbursed for the care that they are giving you.  In order to receive payment from Medicare, Medicaid, or a Private Insurance Company, the Physician has to ensure that the care is aligned to meet your health needs, while still falling within the recommended context of Medical Necessity Criteria.

A Physician Advisor will review your health record, and the care recommended for you by the Physician as a form of checks and balances to ensure that it meets the appropriate Criteria.

If your Physician is seeking to provide care to you that is not standard, or if the care being provided is something which is complex or costly a Physician Advisor may need to perform a case review to ensure that your Insurance Company will authorize the care, or cover the cost of the care given.