February 2019

Why Doctors Review Health Insurance Claims

A recent article in our online magazine, Making the Health Care System Work, pulls the curtain back on one step in the health insurance process that few may know about – clinical review. Why Doctors Review Health Insurance Claims explains how experienced physicians work within our company to offer peer-level review of certain benefit preauthorization requests and claims.

The article touches on the role doctors and nurses take in building a bridge between the care provided to our members and the benefits available with an insider’s point of view. Doctors and nurses on staff with Blue Cross and Blue Shield of Illinois (BCBSIL) have access to policy guidelines, best practices from other providers in the network and the benefit information for the patient’s health plan. They review cases for proper documentation, medical necessity and other criteria.

The article also looks at how clinical reviews may help offer alternative treatments, reduce unwarranted care and recognize fraud, waste or abuse. However, while the peer review process can help identity the right care at the right time in right setting, and identify potential fraudulent or wasteful activity, the doctors who participate know in the end it’s about the member.

Read Why Doctors Review Health Insurance Claims and other articles about issues facing health care in our online magazine, Making the Health Care System Work

The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.