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. Were the criteria correctly applied? Is the denial letter's rationale supported by what the reviewer actually found?
Were the stated criteria (InterQual, MCG, or proprietary) correctly applied to this clinical presentation?
Does the denial letter's stated medical rationale match what the clinical evidence actually shows?
Was peer-to-peer review with the treating physician conducted and documented correctly?
Was the review conducted by a physician in the relevant specialty as required?
Does the UR file contain all required documentation that plaintiff will subpoena?
Overall assessment of whether the denial is documentarily defensible — with specific remediation recommendations.
The Utilization Review Process Audit examines whether a specific adverse benefit or utilization-management decision is clinically and documentarily defensible. It distinguishes a debatable clinical judgment from a criteria mismatch, incomplete record review, unsupported rationale, or process defect.
A denial can be correct in outcome but poorly documented, or procedurally complete yet clinically inconsistent with the record. Those are different risks. The audit reconstructs the decision timeline and compares the rationale, criteria, evidence, reviewer role, and appeal or peer-to-peer activity.
The report is useful to either side because it identifies what the file actually shows. It does not convert every weakness into a legal bad-faith conclusion, and it does not assume that reversal alone proves the original decision was unreasonable.
Request, submitted evidence, initial review, denial, peer-to-peer, appeal levels, supplemental records, and final decision are placed in order.
The criteria, policy language supplied by counsel, clinical guideline, or stated medical-necessity rationale is identified and its lawful availability confirmed.
The stated denial basis is tested against the clinical record actually available at each decision point.
Reviewer qualification, specialty fit where applicable, P2P documentation, notice language, escalation, and consideration of new evidence are examined.
Clinical and process issues are separated and prioritized for remediation, discovery, settlement, or expert escalation.
The final denial letter alone rarely shows what information was available when each decision was made. Logs, criteria screens, appeal submissions, and peer-to-peer records can be decisive.
Findings are divided into clinical basis, criteria application, and process documentation so a weakness in one area is not overstated as failure in all areas.
No. The audit examines what evidence was available, what changed, and whether the original rationale was reasonably supported at that time.
Yes, but process conclusions will be limited and the report will identify what cannot be determined from correspondence alone.
Only where the criteria are lawfully available for the engagement. The website does not imply access to proprietary tools or confidential former-employer information.
It can identify clinical and documentation improvements specific to the reviewed file. Broader policy remediation requires an enterprise scope and appropriate legal/compliance leadership.