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How do claims adjusters work with Medical Records in Claims Case Management?

For claims adjusters, medical records go hand-in-hand with managing their cases and making case decisions based on their insurance claim investigations.

Published on:
March 16, 2023

For claims adjusters, medical records go hand-in-hand with managing their cases and making case decisions based on their insurance claim investigations. To review with the claimant, a claims adjuster must review, organize, and draw conclusions from  medical records to verify and determine the extent of liability as it pertains to the case.

What is the role of a claims adjuster?

Claims adjusters investigate insurance claims to determine the extent of insuring a company or individual’s liability. They review cases by communicating with their claimants, interviewing witnesses, researching police or medical records, and inspecting any property involved in the claim, such as automobiles and homes.

The role is a mobile career, taking individuals anywhere they must go to estimate damage from natural disasters, complete paperwork, deliver consulting, inspections, and more. When it comes to injury claims, this is where the claims adjuster must process medical records and access database healthcare systems to collect important information. 

The insurance healthcare claim processing has five main stages, from the report of the injury to the resolution of the claim. These five steps of claims process are are:

  • First, the claimant will connect with their broker, who will be their primary contact for their insurance policy. Once all the pertinent information is provided, the claims adjuster follows up with the claimant to continue the claims process.
  • Once the claim is officially reported, the claims investigation will begin. The adjuster will investigate and determine the amount of loss or damages covered by the insurance policy and will provide witness testimonies. They also comb through all medical data and review claim liability.
  • When the investigation is completed, the policy is then reviewed. The adjuster analyzes the policy in detail to determine what is and is not covered and determines possible deductibles in the case.
  • The adjuster will partner with experts such as appraisers, engineers, or contractors to lend their expert advice on the damage. Once the evaluation is completed, the adjuster will also provide a list of preferred vendors that can assist with repairing the damage.
  • Lastly, the payment is arranged. After any repairs have been completed, and lost or damaged items have been replaced, the adjuster contacts the claimant to discuss claim settlement and payment. The length of time it will take the claimant to receive payment depends on the severity and complexity of the claim.

Read the full scope of the steps involved in an insurance claim on Northbridge Insurance

How do medical records impact a claims adjuster’s case management?

When evaluating a claim, adjusters must request medical records and potentially ask for an independent medical examination (IME). While working on a personal injury case, the adjuster collects all documentation focused on the claimant’s injuries, medical treatments, and in some cases the IME results.

When focusing on the management of a specific case, claims adjusters may ask for additional information. For example, if the claimant has X-rays taken but only gave the adjuster the doctor’s records, they may also request the radiologist’s records. If there is a possibility of a pre-existing injury, the adjuster may seek out past medical records. Claims adjusters often spend manual time sourcing records from various healthcare providers in order to better understand the patient history and may need to source records decades back in order to make an accurate decision in a case claim.

How has Wisedocs streamlined medical record reviews for insurance companies and independent Adjusters?

Wisedocs is an integral part of processing medical records for claims that adjusters need to investigate. When an adjuster compiles the data for an injury claim, they can expedite the medical record review process and provide more detailed results and findings for the insurance companies with the use of an electronic medical record review, organizing, and summarizing system like Wisedocs.

For example, an IME firm that partnered with Wisedocs stated,

“[We] had a lot of companies pitch their document sorting software over the years, but none have ever come close to what Wisedocs has to offer.”

Wisedocs provide a prompt turnaround time, processing unstructured medical records within hours rather than days, Reducing the time it takes to process case files by over 80%! Wisedocs’ artificial intelligence (AI) platform can process over 750 pages of medical records and other documents within one hour. Wisedocs also identifies duplicated case file information in any uploaded file and processes extraneous information to help claims adjusters complete the case faster and more efficiently.

If you are a claims adjuster or work in the insurance industry, get in touch with our team for a full demo.

Alanna Andersen
Content Writer

Alanna Andersen is a professional freelancer in the art of writing, editing, and proofing. In her past life, she was a Booking Agent and Tour Manager in the music industry and restaurant General Manager in bustling downtown Toronto, Canada. As an avid researcher, she enjoys learning new things and expanding her knowledge. In her spare time, she enjoys travelling around the world, spending time with her cats, dancing to live music, and watching horror films.

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