Investigation Report for Medical Claim

Date of Investigation: October 15, 2024
Claim Number: [Claim Number]
Claimant: [Claimant’s Name]
Prepared by: [Your Name]
Position: Medical Claims Investigator

An investigation was conducted on October 15, 2024, regarding a medical insurance claim filed by [Claimant’s Name]. The purpose of the investigation was to verify the legitimacy of the medical expenses claimed and ensure compliance with the terms of the insurance policy.

Claim Overview:
[Claimant’s Name] submitted a claim on October 1, 2024, for [amount], seeking reimbursement for medical expenses following treatment for [medical condition/accident] that occurred on September 20, 2024. The claim included costs for hospitalization, surgery, and post-operative care.

Investigation Details:

• Medical Records Review:
  The claimant provided hospital records and medical bills from [Hospital/Medical Facility Name]. A review of the records confirmed that the claimant was treated for [medical condition] and underwent [type of treatment, e.g., surgery, therapy]. The medical bills appear to be consistent with standard charges for these services.
• Physician’s Statement:
  A statement from Dr. [Doctor’s Name], the attending physician, verified the need for the surgery and related treatment. Dr. [Doctor’s Name] confirmed that the procedure was performed on September 21, 2024, and post-operative care was necessary to ensure recovery.
• Policy Coverage Review:
  The claimant’s policy provides coverage for [specific medical treatments], including hospitalization, surgery, and post-operative care. A review of the policy shows that the submitted expenses are within the covered limits and meet the criteria for reimbursement.
• Discrepancies Noted:
  The investigation revealed a discrepancy related to the duration of hospitalization. The claim included five days of hospital stay, while the medical records indicate the claimant was discharged after three days. The additional two days of charges were not supported by the medical records.

Findings:
The investigation found that the claim is mostly valid, with legitimate medical expenses for surgery and necessary care. However, there is an issue with the hospital stay being overstated by two days, resulting in an inflated claim amount.

Recommendations:

1. Claim Adjustment:
   It is recommended to adjust the claim by excluding the costs associated with the extra two days of hospitalization. The claim should be processed for the valid medical expenses.
2. Further Verification:
   Contact the hospital billing department to confirm the actual duration of the stay and ensure that the charges align with the medical records.
3. Partial Payout:
   Approve a partial payout for the covered medical expenses and withhold the disputed charges pending further investigation.

Conclusion:
The claim is largely valid, but an adjustment is necessary due to the inflated charges for hospital stay. It is recommended to proceed with a partial reimbursement and verify the remaining expenses before finalizing the claim.

Prepared by: [Your Name]
Position: Medical Claims Investigator