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Bad Faith Defense Service

Utilization Review Process Audit

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. Was criteria correctly applied? Is the denial letter's rationale supported by what the reviewer actually found?

From $600 · 5–7 business days
Founder's Advantage — The Reverse Direction

This is the reverse of the bad faith plaintiff service. Our founding physician knows what a defensible denial looks like because he wrote them — applying InterQual, MCG, and proprietary criteria across 3,000+ payer-side claim reviews. He can evaluate whether the insurer's own UR process will hold up under plaintiff scrutiny because he operated that process first-hand.

What the audit evaluates

  • 01
    Criteria Application Assessment

    Was the stated criteria (InterQual, MCG, or proprietary) correctly applied to this clinical presentation?

  • 02
    Denial Rationale vs. Clinical Evidence

    Does the denial letter's stated medical rationale match what the clinical evidence actually shows?

  • 03
    Peer-to-Peer Documentation

    Was peer-to-peer review with the treating physician conducted and documented correctly?

  • 04
    Reviewer Qualification Assessment

    Was the review conducted by a physician in the relevant specialty as required?

  • 05
    Documentation Completeness

    Does the UR file contain all required documentation that plaintiff will subpoena?

  • 06
    Defensibility Assessment

    Overall assessment of whether the denial is documentarily defensible — with specific remediation recommendations.

Starting Fee
$600
Scope-dependent
Turnaround
5–7 days
Rush available
Invoice
Net 15/30
Institutional terms
View Specimen → Request UR Process Audit →