Utilization Review

MCMC knows that Utilization Review is an effective tool in managing medical services, utilization and costs.

MCMC’s Utilization Review team includes an experienced staff of Registered Nurses, Physicians, Medical Directors, and large panel of Certified Peer Reviewers.  The team uses recognized guidelines and treatment protocols to determine if a claimant’s medical care and treatment was reasonable and necessary.  When the team conducts the review, if the treatment was appropriate, the Utilization Review nurse certifies the treatment.  If the Utilization review nurse cannot certify the treatment, the claim will be referred to MCMC’s Peer Review panel.

MCMC provides comprehensive analysis and information to facilitate claim resolution.

Chronological Medical Record Summary:

Review and analysis of medical records provided in a comprehensive, easily understood report outlining injuries, preexisting conditions, causal relationship and evidence of comparative negligence.  Evidence-based guidelines are used to identify unreasonable or excessive treatment and determine “return to work” timeframes.

Demand Package Evaluation:

Critical analysis of opposing counsel’s medical interpretation of seriousness of injury, permanency, wage loss and projected medical expenses.

Medical Provider Bill Analysis:

Evaluation of medical charge information for correct procedure and diagnostic codes, relatedness and possible errors. Provider charges are compared (where applicable) to a “Usual and Customary” range of fees for the geographical area involved, allowing for quantification of medical specials.

Peer Review Coordination:

Evaluation of all medical records by a qualified, independent specialist to determine what injuries or treatment are related to and medically necessary for, a claimant’s condition or injury.

Independent Medical Evaluation:

Used to determine an impartial diagnosis or prognosis, permanency or rating from injuries that a claimant may have sustained in an accident or incident.

MCMC Offers:  

  • Professional Review nurses with extensive medical/legal experience
  • Flexible report formats
  • Ability to accommodate expedited reviews
  • Demonstrated outcomes
  • For more information call 617-375-7766, or email us at paul.gilleece@mcmcllc.com