What is the purpose of a retrospective review in health insurance?

The purpose of a retrospective review in health insurance is to evaluate the medical necessity of services that have already been provided. This process involves examining patient records and the treatments administered to determine if they were appropriate and justified based on the patient's condition at the time of care. By assessing the medical necessity post-service, insurers can ensure that claims are valid and that the care provided aligns with established guidelines and protocols.

In addition, this type of review plays a critical role in managing healthcare costs, as it can identify instances where unnecessary treatments were given. It helps insurance companies make informed decisions about coverage, future treatments, and overall healthcare management.

Other options reflect different aspects of health insurance processes, such as claims review or provider credentialing, but they do not specifically address the evaluation of medical necessity after care has been rendered, which is the essential focus of a retrospective review.