Written for people who have to make decisions about demand packages — whether or not they ever work with us.
Forty-one terms defined plainly — demand package, causality, medical necessity, letter-of-protection billing, NCCI edits, loss adjustment expense. Grouped the way a claim moves rather than alphabetically, so reading it start to finish teaches the sequence.
Useful if you are new to third-party demand review, or briefing someone who is.
The four-step framework a defensible review follows: audit the bills against the fee schedule, test the treatment against the clinical evidence, build a position rather than just a lower number, and apply the same standard every time.
Useful if you are deciding how your own team should handle demands, whoever performs the review.
Why a fully automated review cannot produce a defensible finding — a model cannot be deposed, its errors correlate across an entire book rather than scattering, and causality has no answer sitting in the file waiting to be extracted.
Useful if you are evaluating software that promises to read medical records for you.
Everything here is general reference. Liability claims are governed state by state, and nothing on this site is legal advice. If a term or a procedure matters to a claim you are working right now, the answer depends on your jurisdiction.
More is planned — letter-of-protection billing, what a time-limited demand actually obliges an insurer to do, and how bill audit, nurse review, peer review, and an independent medical examination differ in cost and in what each can establish.
Bring a demand package you are working on. We'll walk through where each of these ideas shows up in it — no commitment.
30 minutes · No commitment · Pick a time that works for you