Why Doctors Review Health Insurance Claims

Feb. 1, 2019

A recent article published in our online magazine, Making the Health Care System Work, pulls the curtain back on one step in the health insurance process that few know about — clinical review. Why Doctors Review Health Insurance Claims explains how experienced physicians work within our company to offer a 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 our members need and the business requirements with an insider's point of view. Doctors and nurses on staff with BCBSTX 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 offer alternative treatments, reduce unwarranted care and recognize fraud, waste or abuse. However, while the peer review process can help hold costs in check and identify potentially fraudulent or wasteful activity, the doctors who participate know in the end it's about the member, not about the money.