Workflow — Medical Records
Medical timelines in hours, not weeks.
100–2,000 page medical packets — chronological treatment timeline, diagnosis codes, causation gaps, lien holders. Defensible adjuster work product at one-third the per-file cost.
$250–$800
Per file at nurse case managers and offshore medical reviewers
100–2,000
Pages per BI medical record packet
60–85%
Volume off the BPO line after cutover
What This Replaces
The Nurse Case Manager Doing 3-Week Medical Reviews
The work the nurse case manager or offshore medical reviewer does on every BI file — and the cost of leaving it there.
The labor
BI medical reviews today move through nurse case managers and offshore medical reviewers at ExamWorks, MedReview, Genex, and similar vendors. Fully-loaded per-file cost: $250–$800 per file, higher on large-loss and complex multi-provider files.
The cycle time
Turnaround of 2–6 weeks is standard, longer on multi-provider records or out-of-network IMEs. Every week the file sits is a week reserves don't get refined, settlement authority isn't sized correctly, and the demand letter that's coming gets harder to negotiate against.
The Workflow
Input · Analysis · Output
What goes in, what we do to it, and what shows up in your claim file.
Input
Medical record packet
- Provider records (PCP, specialists, ER)
- Hospital discharge summaries
- Imaging reports (radiology, MRI, CT)
- IME and peer-review reports
- Pharmacy records
- Physical therapy and rehabilitation notes
- Pre-loss treatment history (where available)
Analysis
Extract, structure, flag
- Chronological treatment timeline
- Diagnosis codes (ICD-10) and procedure codes (CPT)
- Provider names, dates of service, paid medical to date
- Causation gap identification against the loss event
- Pre-existing condition flags with source citations
- Lien holders and outstanding balances
- Confidence threshold routing to nurse case manager
Output
Adjuster-ready summary
- Claim file summary into Guidewire ClaimCenter
- Duck Creek Claims (OnDemand APIs)
- Origami Risk (REST API)
- ISO ClaimSearch update with diagnosis pattern
- Subrogation queue routing if applicable
- Source-page citations on every extracted item
- Field-level audit log per file
Side by Side
Medical Review Today vs. With Last Rev
The numbers that matter: cycle time, per-file cost, defensibility, and audit posture.
| Dimension | Nurse Case Manager / Offshore Reviewer | Last Rev Medical Summarization |
|---|---|---|
| Cycle time per file | 2–6 weeks | 2–6 hours for routine, same-day for most |
| Per-file cost | $250–$800 typical | 30–50% of BPO unit cost, volume-tiered |
| Surge capacity | Add nurses or contract more reviewers | Elastic by design |
| Source citations on every extracted item | Variable — depends on reviewer | Page-level citation per field, every time |
| Causation analysis | Yes, in narrative form | Structured flags with source pages, narrative on top |
| Pre-existing condition detection | Reviewer-dependent thoroughness | Cross-reference against pre-loss records when available |
| Defensibility against deposition | Reviewer testifies to their methodology | Every extraction traces to source page + model version |
How It Works
From Records Receipt to Adjuster-Ready Summary
Five steps. Every one logged. Every one reversible if your confidence threshold isn't met.
Records Land
Index and ingest 100–2,000 page medical record packets from providers, IMEs, hospitals. PDF, fax, encrypted portals — whatever the records-release vendor sends. OCR if needed, classify by provider and date range.
Extraction & Classification
Diagnosis codes (ICD-10), procedure codes (CPT), medications, providers, dates of service, paid medical to date, lien holders. Build chronological treatment timeline. Identify causation gaps and pre-existing conditions.
Validation Against Claim Rules
Causation analysis against the loss event, treatment-plan compliance with state medical guidelines, ISO ClaimSearch cross-reference for prior-claims patterns. Anything below your confidence threshold per field is routed to a human exception queue — your call which queue, ours or yours.
Push to System of Record
Claim file summary delivered to the adjuster in your claims system (Guidewire ClaimCenter, Duck Creek Claims, Origami Risk, or your AMS). Subrogation queue routing if applicable. ISO ClaimSearch update.
Audit Log Persisted
Every diagnosis, procedure, date, and dollar amount traced back to the source page in the original record. Model version, prompt, and confidence score recorded. Discovery-ready and defensible against deposition.
Compliance & Defensibility
Built to Meet the Quality Bar Claims Operations Already Run On
HIPAA & Business Associate Agreement
PHI redacted before logging; encryption in transit and at rest; BAA in place; retention policies tied to your HIPAA documentation. Deployable in your VPC for stricter posture.
ISO ClaimSearch & prior-claims patterns
Cross-reference against ISO ClaimSearch and prior-loss patterns surfaced at summary time. Pre-existing conditions and recurring-claimant signals flagged for SIU review.
Discovery defensibility
Every diagnosis, procedure, date, and dollar amount traces back to a specific source page. Holds up to deposition and DOI exam without reconstructing reviewer notes.
State medical-treatment guidelines
ODG (Official Disability Guidelines) and ACOEM applied for workers' comp files. State-specific PIP and BI guidelines configured during onboarding.
Common Questions
What Carriers Ask About Medical Record Summarization
How is this different from existing medical-review vendors — ExamWorks, MedReview, Genex?
Those vendors sell the labor — nurse case managers, RNs, sometimes offshore medical reviewers. The competitor on this page is the per-file fee on your claims operating budget for that labor — typically $250–$800 per file at named medical-review vendors. We replace that labor cost, integrate directly into your existing claims system, and deliver a structured claim file summary into the system of record.
We have a contract with a nurse case management or medical review vendor. How does this work alongside it?
Most carriers run AI on the front of the funnel — initial summarization, timeline construction, causation flagging — and route exceptions and high-stakes files to the nurse case manager. Volume to the BPO drops 60–85% on routine BI medical reviews once cutover completes. Your contract is unchanged in pilot and early production — you renegotiate at the next renewal from a much better position, or shift the contract to higher-complexity reviews (large-loss, surgical-recommendation, IME-disputed) where the nurse-case-manager judgment actually matters.
What's your accuracy bar versus a nurse case manager?
Our pilot success threshold is structured-field extraction accuracy at parity with or above your incumbent reviewer, measured on the same shadow-data sample (same files, same target outputs). We don't make the medical-necessity determination — we tag the file with the diagnosis codes, treatment timeline, causation flags, and source-page citations, so your adjuster or nurse case manager makes the call on a richer file than they get from offshore review today. Anything below your defined confidence threshold per field is routed to a human exception queue.
What about HIPAA, state privacy law, and discovery defensibility?
Deployable in your VPC or our SOC 2 / HIPAA-aligned environment. PHI is redacted before logging; encryption in transit and at rest; retention policies tied to your DOI and HIPAA business-associate agreement. Every extracted item traces back to a specific source page and a specific extracted clause, so the file holds up to deposition and DOI exam.
Can you actually integrate with Guidewire ClaimCenter / Duck Creek / Origami / our AMS?
Yes — through the standard integration surfaces each platform supports. Guidewire via the ClaimCenter REST API or the EDGE integration framework; Duck Creek via OnDemand APIs; Origami Risk via their REST API. ISO ClaimSearch via the documented integration. Your IT team reviews and approves a service account, and we connect through the documented integration. We do not require platform-side custom development.
How long until a pilot is live?
Medical record summarization pilots typically run 6–8 weeks: 1–2 weeks of integration and rule mapping (which carriers, which LOBs, which state-specific medical guidelines), 4 weeks of shadow-mode running on real files with no system-of-record writes, 1–2 weeks of supervised cutover on a constrained book (BI claims, one region, defined severity bands). Production rollout is staged after the pilot meets your accuracy and SLA bar.
What's the per-file pricing structure?
We benchmark against your current per-file medical-review unit cost — typically $250–$800 per file at nurse case managers and offshore medical reviewers. Our target is 30–50% of that per-file cost at higher accuracy and faster cycle time. Pricing structures around volume tiers and outcome SLAs, not hourly billable rates.
Is this a good fit for workers' comp medical reviews too?
Yes. The workflow is the same — extract diagnosis codes, build treatment timeline, validate against state medical-treatment guidelines (ODG, ACOEM), identify lien holders. The state-specific guideline application is configured during onboarding. WC medical reviews typically have higher per-file complexity and stronger ROI math.
Two Ways to Start
Take the AI assessment for a structured read on medical-review feasibility in your operation. Or talk to us if you already know which BI files are sitting in the queue too long.
Self-serve · 8 minutes
Take the AI Assessment
A short structured assessment that maps your BI medical-review volume, current vendor unit cost, and claims system of record to AI feasibility and ROI.
Talk to a specialist
Get a Per-File ROI Model
Send us your monthly BI volume, current nurse case management or medical-review vendor, and target system of record. We'll come back with a per-file comparison and a 6–8 week pilot plan in 5 business days.
Other Workflows
More Insurance Workflows We Replace
The same approach, applied to the other claims-document labor lines on your operating budget.
FNOL Intake
First-notice-of-loss extracted, validated, and pushed into Guidewire ClaimCenter, Duck Creek, Origami, or Snapsheet in minutes.
Acord Form Processing
Acord 1, 25, 27, 125, 130 — every field extracted and validated against carrier business rules.
Demand Package Review
Attorney demand packages — claim valuation drivers and reserve recommendations in days, not weeks.
Property Estimate Review
Xactimate, Symbility, Verisk 360Value line-item review and supplemental flagging.