Retrospective Review is a review of medical necessity performed after the service has been provided.  As with pre-certification, this review provides an evidence-based opinion of medical necessity for a proposed treatment based on submitted medical documentation and evidence-based treatment guidelines.   

Retrospective reviews can include coding review/DRG validation, appropriate setting, billing error, quality of care review and medical bill audits.    

Retrospective reviews can be very important in the emergency room setting.  Typically emergency room care is not authorized and often the care and procedures rendered are not medically necessary.

Appropriate Setting reviews focus on the patient’s medical records to determine whether the hospital, ASC  or other services provided were appropriate.

Coding Review/DRG Validation review focuses on reimbursement is based on diagnosis and procedure codes, such as Diagnosis Related Groups (DRGs).

Quality of Care focuses on medical record reviews specially for medical necessity.

Medical Claim/Bill auditing focuses on healthcare claim reviews against medical records to verify medical procedures and supplies claimed were performed, necessary and not over-billed or un-bundled vs. bundled.

For our Workers Compensation clients, SFUR often will deny selected line items on a bill because they are not related to the work injury.

In this example Patient XXX is a 67 year old Male who presented to the Emergency Department (ED) with neck and back pain for 1 week.  He denied any injury. The pain was worse with breathing.  Due to the location (shoulder blade area) and pleuritic nature of the pain a pulmonary embolism (PE) was suspected.

A CT chest was interpreted to show that he did have a pulmonary embolism (a blood clot in the lung).  There is no indication that this was related to any work-connected injury.  He was admitted to medicine for treatment of the presumed PE (not for a work-related injury).  He had acute kidney injury, felt to be related to the contrast injection for the CT thorax to r/o PE.

It was subsequently determined that the first CT was a FALSE POSITIVE result and in fact the patient did not even have a PE. The MRI of the Right shoulder reportedly showed evidence for a rotator cuff tear.  Although surgery for the shoulder issue was considered, it was determined to treat non-operatively at least for the time being.

In any case, this type of surgery is commonly performed in an outpatient setting after documentation of medical necessity. He had an MRI lumbar spine, because of chronic back pain – no history of any acute injury to this area.

The SFUR conclusion of the patient who is reported to have a history of chronic neck/back/shoulder pain presented with pain in the Right scapular area which was worse with respiration.  The admission to the hospital, 2 chest CT scans, false positive diagnosis of PE and subsequent cardiac workup are unrelated to a musculoskeletal condition which itself may not even be work-related.

SFUR denied the charges related to the musculoskeletal complaint of shoulder/neck pain including the MRI of the shoulder, the CT scan of the cervical spine, the ED visit charge.  The payer (self insured employer group) paid $24,222 out of the total billed charges of $111,580 which is a savings of $87,358. This denial was never appealed or petitioned by the provider.

In this particular example $87,358 was saved out of the original bill of $111,580. Typically in a bill review scenario where SFUR only generates a fee if savings are found, the payer would have only paid a percent of the savings to SFUR.  Retrospective reviews can also be performed for other non-Bill Review reasons and in those instances, the fee would be fixed based on the amount of the time the reviewing physician spent.