What does 'retrospective review' involve in health insurance?

The concept of 'retrospective review' in health insurance pertains specifically to the evaluation of care after services have been provided. This involves analyzing the records and outcomes of patient care to ensure that the services rendered were appropriate, necessary, and compliant with established guidelines and standards. The goal of this review is often to assess the quality of care, identify any potential areas for improvement, and ascertain whether the treatment was aligned with the patient's needs and the health insurance policy's requirements.

The focus on post-service evaluation distinguishes retrospective reviews from other types of reviews, such as prospective assessments, which look at care plans before services are delivered, and continuous monitoring, which tracks health outcomes over time rather than evaluating specific past events. By understanding the correct definition of retrospective review, one can better comprehend how health insurance plans assess the efficacy and appropriateness of delivered care.