Medical Record Summarization vs. Insights: Why the Difference Matters for Claims Professionals

Medical record summarization is a relatively new, yet already critical tool for claims professionals, helping them sift through mountains of medical files to extract key information. But summarization alone isn't enough. The real value lies in insights—not just knowing what is included in the records, but understanding what each piece of information means and exactly how it impacts the claim.

The Limitations of Basic Summarization

Traditional medical record summarization tools focus on condensing vast amounts of medical documentation into digestible formats. They can highlight diagnoses, treatments, and test results, reducing the time spent manually combing through files. However, they often fall short in answering the most critical questions claims professionals face:

• What’s new or changed in this case?
• Is there conflicting medical information?
• How does this claimant’s medical history impact their return-to-work potential?

Basic summarization leaves claims professionals to manually interpret the significance of each piece of medical data. Because it is simply extraction-based, basic medical record summarization tends to be lengthy, convoluted, and repetitive. For the claims professional working up the claim, this means that there’s still a fair amount of digging to be done on the part of the reviewer to get to what really matters. 

The process of parsing out what’s relevant from what’s not is excruciating, exhausting, time consuming, and error-prone. When implementing any AI solution, it’s imperative to minimize errors presented to a user, whether factful mistakes or surfacing irrelevant information.

Inaccuracies in summarization solutions quickly lead to mistrust and erode usage, impacting efficiency and ROI. Solutions that are built out-of-the-box based on publicly available GPTs and LLMs are the most likely to fall into this trap: 

1. Summarization is incomplete and does not provide a full picture of the medical context of a claim
2. Surfaced summarizations of historical medical documents are irrelevant to the current claim and waste the time of a claims professional
3. The tool is unable to generate a summarization for a claim or medical documents altogether

Each of these downfalls generates inefficiencies, inconsistencies, and the risk of missing key information that could alter the trajectory of a claim.

The Power of Insights in Claims Decision-Making

Insights refer to critical and timely pieces of medical information related to the claim that can alter how the claim professional working up the claim thinks about next steps or outcome. Insights go beyond summarization by analyzing and contextualizing medical data in a way that helps claims professionals make better, faster, and more confident decisions. Instead of just listing a claimant's past diagnoses, insights surface patterns, contradictions, and medical changes that demand attention.

For example, a claim is filed for an employee who experienced a back injury at a construction site. As required by the employer’s workers compensation policy and treatment, the claimant submits their relevant medical documents, which include a previous back injury from a skiing accident years ago. 

Basic medical record summarization would produce a transcript of each multi-page medical document, creating succinct summaries for each procedure. However, those summarizations highlighted similar medical facts from the previous injury and treatment, presented with the same weight as the current treatment. Adjusters can easily confuse the two time periods, treatment plans, and recovery timelines with basic summarization. 

However, surfaced insights would uncover the one or two most critical pieces of information from those injuries, highlight any significant patterns to be aware of, and deliver them in a digestible format. 

How Insights Transform Claims Handling

Having access to true insights can significantly improve a claims professional’s ability to work through, decipher, and triage the most critical pieces of medical information in a claim file. By incorporating medical insights into claims workflows, professionals can:

• Work up cases faster – No more wading through hundreds of pages to find a critical update.
• Improve consistency – Ensure all claims professionals have a clear, standardized view of key medical factors.
• Reduce leakage and adverse claim development – Detect medical changes in real-time to prevent unnecessary claim extensions.

These benefits aren’t just theoretical—they’re being experienced by leading carriers today:

“Medhub enhances our claims professionals' ability to deeply understand their claimants' medical circumstances, and be a partner on the claimant’s return-to-health journey.” —VP, Group Insurance Claims, Top 10 Carrier

“People spend hours summarizing records. I can free that time up to do other, more valuable decisioning work. It is a true game changer.” —Head of Claims, Top 10 Carrier

“I am able to pull Medhub up really quickly and see what has happened over the last 6 months...It gives me an immediate insight, whereas before, it might have taken me close to 30 minutes.” —Senior Claims Professional, Top 10 Carrier

While summarization is useful, insights are what drive better outcomes. For claims teams navigating complex medical cases, the ability to instantly pinpoint critical changes and contradictions can mean the difference between an efficient resolution and a costly, drawn-out claim.

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