Medical Review Fundamentals and Professional Standards
This domain frames how a review is scoped, who may perform it, and what makes a finding defensible. Expect items on review types, the hierarchy of authority you must cite, and the professional-conduct rules - independence, competence, and written rationale - that separate a review from a personal opinion.
Review types and scope
- Prospective (pre-payment, often prior authorization), concurrent (during the stay or episode), and retrospective (after payment). Each has different leverage and different fairness risks.
- Distinguish coding/compliance audits (was the code supported?) from clinical medical necessity review (was the service indicated?) from payment-integrity review (was the claim paid per policy?).
- The scope statement fixes the sample, the period, the criteria version, and the exact question answered. A review that drifts outside its scope loses credibility on appeal.
The evidence hierarchy
Apply the most authoritative source that actually governs the claim: statute and regulation, then NCD, then LCD or payer medical policy, then licensed screening criteria (InterQual, MCG), then specialty-society guidelines, then local custom. Screening criteria are decision support, not regulation - a reviewer may depart from them, but must say why and point to record evidence.
What a defensible finding contains
Reviewer name and credential; dates of service and documents reviewed; the criterion with citation and version; the elements met or not met; the decision; the rationale in clinical language; and the notice and appeal rights communicated.
Independence and competence
Recuse yourself from records involving family, self, or a facility you are employed by. Stay inside your licensure and training. Reviewers are measured on inter-rater reliability, which requires applying the same criterion the same way across cases.
Worked example
A one-night admission for chest pain, negative troponins, negative stress test. The reviewer is tempted to deny because the stay was short. The correct reasoning: ask whether, at the time of the admission order, documentation supported an expectation of two midnights and met the payer's chest-pain criteria. Cite the specific criterion element that failed (for example, no high-risk features, serial troponins negative, provocative testing completed), state the information available at admission, and note that the decision is not based on the eventual outcome. Do not cite the discharge diagnosis as the reason for denial.
Traps that cost marks
- Hindsight bias - judging admission using discharge results.
- Applying today's criteria version or code set to an older date of service.
- Substituting personal clinical preference for a cited criterion.
- Writing "not medically necessary" with no element-by-element analysis.
- Deciding based on cost or on the plan's financial interest rather than the record.