“Tips for Utilization Review & Medical Management”

Have you considered the totality of circumstances?

Can you determine the rationale for why to admit or not?
     Through documentation, we look for the medical justification and thought process for determinations.

Can the Medical Director or Specialist Consultant come to a reasonable & defensible determination or recommendation for the next step?

Have you paid special attention to the allegedly disabling condition?

“Tips for Case Managers, Claims Examiners & Adjusters”

What is the question?
     The more targeted your question can be, the more targeted MDS’ response will be.

Are you asking for us to determine matters of fact, interpretation or law?


Have you analyzed the contents of the well prepared file?

Minimally, we look for the following:

* Attending Physician Statement-matching the claimants’ disability assertion from the relevant treating physician.

* Employee Statement-updated to reflect current circumstances.

* Clinical Documentation-particularly from prior to the last day worked (LDW).

* List of Medications-prescribed by all physicians.

* Case Summary-both yours and other narratives.

* Hospital discharge summaries

* Diagnostic Tests’ results

Are you aware of the “Litany” of frequently stress related or mental/nervous conditions and self-reported diagnoses?

Potential Stress Related or Mental/Nervous Conditions

* Chest pain of unknown etiology

* Abdominal pain of unknown etiology

* Shortness of breath or unknown etiology or “Asthma”

* Intractable headache

* Chronic fatigue

* Sleep dysfunction

* TMJ disorder

* Gynecological pain including dyspareunia of unknown etiology

* Nicotine addiction

* Other dependencies

* Doctor shopping

* Alternative therapies

* Abnormal eating or bowel disorders

* Irritable Bowel Syndrome

* Unsubstantiated conditions

“Self-Reported” Diagnoses

* Fibromyalgia

* Chronic Fatigue Syndrome

* Intractable Headache

* Chronic Pain

* Interstitial Cystitis