Medical Review Criteria
Medical reviews are usually conducted by insurance companies, third-party payers, review organizations and case managers. This is the underlying basis for reviewing the quality and appropriateness of care provided to selected cases. Insurance companies rely heavily on medical review and their own criteria as cost control. Through medical reviews, payers are able to limit or reduce the utilization of healthcare services. Medical review may sometimes put patients at odds with their insurance companies or hospitals and doctors in conflict with payers.
