When a patient or provider sues an insurer over a wrongful denial, the central legal question is whether the insurer's physician reviewer applied criteria correctly. Our lead physician performed that exact review function.
Did the insurer’s reviewer correctly apply the stated medical necessity criteria, or did the denial use criteria that do not support the stated rationale?
Was the review conducted by a qualified physician in the relevant specialty? Was the treating record actually reviewed?
Is the denial letter’s stated medical rationale supported by the clinical evidence, or is it boilerplate language that does not address the specific clinical presentation?
Did the insurer’s reviewer engage in the required peer-to-peer review with the treating physician before denial?
Medisprudence does not use confidential, proprietary, or plan-specific information from any current or prior employer. All analysis is based on publicly available clinical guidelines and general utilization review methodology. Conflict checks are conducted at intake.
Via the IME deconstruction framework applied to the denial letter — criteria application assessment, record vs. denial comparison.
Pre-litigation medical exposure mapping for insurers and defense counsel.
Does the record support the claim the denial addressed? Pre-expert screening for bad faith plaintiff teams.
Comprehensive seven-component analysis for high-value bad faith matters.
When a plaintiff sues an insurer for bad faith denial, the insurer's defense team needs to know whether the UR process is documentarily defensible. Our founding physician's credential is equally compelling from this direction: he knows what a defensible denial looks like because he wrote them.
Was criteria correctly applied? Is the denial letter's rationale supported by what the reviewer actually found? Was peer-to-peer documented correctly?
Pre-litigation assessment of where the insurer's denial documentation is most and least defensible under plaintiff scrutiny.
Physician-authored exposure assessment for carrier reserve committees on bad faith claims.