Glossary of record review buying terms
Short definitions of the words that show up in record review quotes and contracts. Where a term has a legal meaning, it varies by state and program, so check the rule that governs your file.
Limits: We have not ordered work from the services listed: prices and turnaround times are what each service publishes on its own site on the date shown, and the worked example uses a synthetic file.
What you are buying
- Medical chronology
- The base product of most review services: 1 line per encounter in date order, giving the date, provider, what happened and the source page.
- Narrative summary
- A prose account of the course of care, written from the chronology. Easier to read, harder to check, and often billed as an add-on.
- Billing summary
- A table of charges by provider and date of service. Bought mostly by claims and risk teams.
- Deposition summary
- A summary of a deposition transcript, not of medical records. Usually priced per transcript page, at a higher rate than records.
- Missing records list
- Records that the file refers to (a scan ordered, a consult requested) but that were not produced. Several services list it at no charge.
- Hyperlinked index
- A table of contents for the record PDF in which each entry jumps to its page. Makes a chronology quick to check.
- External peer review
- Review of a physician's care on a specific case by a reviewer from outside the hospital, used when internal reviewers are conflicted, lack the specialty or can't agree.
- IME
- Independent medical examination: an exam by a physician who is not treating the patient, ordered for a claim or a dispute. The examiner reviews the records before writing the report.
- QME
- Qualified medical evaluator: a physician certified by California's Division of Workers' Compensation to perform medical-legal evaluations.
- ML-201
- The California billing code for a medical-legal evaluation that is not a follow-up or supplemental. It pays $2,015 including 200 pages of records, then $3.00 a page (8 CCR 9795, effective April 1, 2021).
How the work is done
- Deduplication
- Removing exact repeat pages before the file is read or billed. Matters most when records arrive from several providers.
- Page citation
- The page number after each fact in a summary that tells you where to check it. The single best quality signal in a chronology.
- Bates numbering
- A unique number stamped on every page of a production so that any page can be cited without ambiguity.
- AI-assisted review
- A service in which software sorts or drafts first and a person at the vendor reads and corrects before delivery.
- Software-only review
- You run the software yourself; no person at the vendor reads the file. You check the output.
- Record retrieval
- Requesting and collecting records from providers. A separate purchase from review, with its own clock and fees.
Contract and price terms
- Statement of work
- The document that fixes the deliverables, format, turnaround, price basis and acceptance rules for a job. See the template.
- Case minimum
- The lowest charge per file, whatever the page count. A $150 minimum on a 200-page file at $0.25 a page triples the effective rate.
- Turnaround time
- The time from a stated start event to delivery. Read the start event: upload, approval of the estimate or payment.
- Rush fee
- The extra charge for faster delivery, as a percentage or a flat fee. Published examples run from free to 20%.
- BAA
- Business associate agreement: the HIPAA contract a vendor signs before it may receive protected health information from you.
- PHI
- Protected health information: health data that identifies a person and is held by a covered entity or its business associate.