Practical reading for litigation teams. Written from the perspective of a physician with payer-side US claim review experience under InterQual and MCG, now applying that lens to plaintiff and defense work.
The missing piece in ERISA benefits defense: a clinician who has actually applied the criteria under dispute. Why compliance attorneys and actuaries cannot answer the central clinical question.
The four-dimension test a physician reviewer applies to every denial. Written from first-hand criteria application — the operational standard, not the legal standard.
Most MHPAEA writing is legal. This is operational — what each of the six NQTL categories looks like from inside the utilization review operation, and where the disparities actually emerge.
Defense and carrier orientation. Written for in-house counsel and defense firms preparing for bad faith litigation.
Written from first-hand criteria application experience. For insurance defense counsel and carrier legal teams.
The mirror image of the seven IME defects — applied to plaintiff expert reports. What defense counsel should look for before deposition.
What a physician-authored reserve analysis provides that a claims adjuster cannot. Why documented defensible reserves matter in bad faith exposure management.
The same seven-defect framework — but for defense counsel who commissioned the IME. What the plaintiff will attack, and how to address it before submission.
Prior pathology is the single most common defense angle in soft-tissue and orthopedic PI cases. What the documentation has to show to reduce its impact — and the temporal markers that strengthen an aggravation theory.
Two services that look adjacent on the surface and are structurally different in what they can defensibly assert. When each is the right answer, and how firms that use both organize the work.
The economics of pre-expert screening when expert retainers start at $2,500 and run to $15,000+. What screening catches that the first expert call won't, and when screening is unnecessary.
The civil causation standard is conceptually simple and operationally subtle. What a physician reviewer looks for when asked whether the record supports the 51% threshold — and the four most common reasons records fall short.
Defense IMEs follow a recognizable internal logic with recognizable failure modes. The seven defects that appear in the majority of reports we read, with the deposition question each one supports.
Most discussion of utilization review is written from the outside. This is written from first-hand application of the methodology. What the mental model actually is, why it produces the denials it produces, and what it means for litigation records that travel through similar reviewer logic.
New pieces are added as clinical and methodological questions arise from active engagements. Referenced in case letters when directly relevant to the matter.
Request Case Review