Through the Medical Care Ombudsman Program, MCMC provides a variety of medical case review services to help our clients make informed, cost-effective health care decisions.

Our case reviews are designed to help determine health plan issues, including pre-determination; decide such issues as disability, back-to-work, workers’ compensation or pre-existing conditions; and investigate fraud, waste and abuse in medical care.  Conducted by board-certified physicians and other health care practitioners, our evidence-based medical reviews include expert advisory opinions, appeals of health plan coverage denials, reviews of experimental or investigational treatments, determination of medical necessity issues, and telephone consultations to review a particular case.

Our services include:

• Case series reviews for clients who have questions about quality of care issues, including resource utilization, pertaining to both high and low technology treatments.

• Service series reviews that deal with quality of care, resource utilization or billing issues for the same or similar diagnostic or therapeutic modalities.

• On-site reviews to examine medical and service records and reports for quality of care audits and billing issues.

• Independent standard of care reviews in which we audit a practitioner’s quality of care.

While clients can choose the number of reviewers on a panel, we recommend a three-expert panel, especially for complex or controversial cases such as those involving experimental or investigational treatments. Reviewers are appropriately matched to cases so our clients are assured of receiving the expertise required for their reviews. With our large network of reviewers, we can add experts to our panel to ensure that we match cases at the subspecialty level, if necessary.

Case Review Questions Often Addressed:

• Is there sufficient scientific evidence to expect that the recommended treatment plan is likely to have health benefits for this patient?

• Is there a beneficial alternative treatment for this patient?

• What is the expected magnitude of the health benefits and/or risks of the proposed treatment, especially in relation to the next best or better alternative?

• Is there sufficient information about the patient’s history and the recommended treatment plan to provide a reasoned opinion?

• Can the provision of treatment, in whole or in part, reasonably be expected to be beneficial for the patient and/or can withholding treatment, in whole or in part, reasonably be expected to adversely affect the patient’s health?

For more information on MCOP's extensive services, please call 888-313-6267, 301-652-1818 or e-mail mcman@mcman.com.