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🔍 '''Retrospective review''' is an evaluation conducted after medical treatment has already been delivered, used by [[Definition:Health insurance | health insurers]] and [[Definition:Managed care organization (MCO) | managed care organizations]] to assess whether the services rendered were medically necessary, appropriately coded, and consistent with the [[Definition:Policyholder | policyholder's]] plan benefits. It stands in contrast to [[Definition:Prior authorization | prior authorization]] (prospective review) and [[Definition:Concurrent review | concurrent review]], which occur before or during treatment. In practice, retrospective review is one of the primary [[Definition:Utilization management | utilization management]] tools insurers deploy to contain costs, detect [[Definition:Fraud, waste, and abuse | fraud, waste, and abuse]], and ensure [[Definition:Claims | claims]] payments align with clinical standards.

📋 During a retrospective review, [[Definition:Clinical reviewer | clinical reviewers]] — typically nurses or physicians employed or contracted by the insurer — examine completed [[Definition:Medical record | medical records]], [[Definition:Billing code | billing codes]], and [[Definition:Explanation of benefits (EOB) | explanation of benefits]] data against established [[Definition:Clinical guideline | clinical guidelines]] and the specific terms of the insurance contract. If the reviewer determines that a service was not medically necessary or was billed at a higher complexity level than warranted ([[Definition:Upcoding | upcoding]]), the insurer may deny or reduce the [[Definition:Claim payment | claim payment]], recover an [[Definition:Overpayment | overpayment]], or flag the [[Definition:Provider | provider]] for further audit. The process typically includes an appeals pathway, giving providers and members the opportunity to submit additional documentation before a final determination is made.

⚖️ The stakes of retrospective review extend well beyond individual claim dollars. Patterns uncovered during these reviews feed into broader [[Definition:Data analytics | data analytics]] programs that help insurers identify outlier providers, detect emerging [[Definition:Insurance fraud | fraud]] schemes, and refine [[Definition:Network management | network management]] strategies. At the same time, overly aggressive retrospective denials can damage [[Definition:Provider relations | provider relationships]], trigger regulatory scrutiny, and generate member complaints that affect an insurer's [[Definition:Quality rating | quality ratings]]. Striking the right balance — rigorous enough to protect plan integrity, fair enough to preserve trust — is a persistent challenge for [[Definition:Claims administration | claims administration]] teams and a frequent focus of [[Definition:State insurance department | state regulatory]] oversight.

'''Related concepts:'''
{{Div col|colwidth=20em}}
* [[Definition:Utilization management]]
* [[Definition:Prior authorization]]
* [[Definition:Concurrent review]]
* [[Definition:Medical necessity]]
* [[Definition:Claims adjudication]]
* [[Definition:Managed care organization (MCO)]]
{{Div col end}}

Definition:Retrospective review - Revision history

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