Medical Rehabilitation Consultants
Medical Case Management
Utilization Management
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MRC has been recognized by
Pacific Lutheran University
as a finalist in the
Washington Family Business of the Year Awards
for 2007, 2006 and 2002.

Case Summaries

Utilization Review Cases

The purpose of Utilization Review is early identification of potential high-dollar and high-risk procedures and services. We target and medically manage the plan’s most costly services to determine medical necessity and review the proposed plan of treatment for medical appropriateness, determine whether the services should be provided and if alternative options have been considered that may be less costly and/or more effective.

The Utilization Review Nurse gathers information regarding the nature of the services and the underlying medical problems. After all of the information is obtained, a determination is made regarding the medical necessity, appropriateness and relatedness of the service, length of stay, number of treatments, etc., prior to certification and according to your established guidelines. There are occasions when review and research indicate the requested services are not appropriate, they do not meet medical necessity criteria or the services are not necessary. By the Utilization Review Nurse making this educated determination, the client may avoid an invasive unnecessary procedure or other services. In turn, this preserves the client’s benefits and co-pays and saves the account from paying unnecessary medical fees.

For Case Summaries of cost savings through review by Utilization Review professionals, please follow the links below;

Medical Case Management Cases

Medical case management involves an in-depth management program for participants with catastrophic or chronic illness or injury and helps in ensuring compliance, complete communication, and face-to-face communication with all involved parties. Medical Case Management is defined as the timely coordination of medical care to meet an individual's healthcare needs and maximize the use of benefit dollars while supporting a quality medical treatment plan. MRCs Nurse Consultant reviews the entire picture of the participant's health and medical status, problems, necessary treatment, treatment being given and alternatives to care. It also includes a review of the cost of services, drugs, equipment, supplies; price negotiation; and long-term cost estimates.

By providing early intervention and care, and by direct contact with the participant, family and providers, MRC’s Nurse Consultants have knowledge of the needs of the participant for necessary treatment and appropriate care. By having this knowledge in conjunction with the Nurse Consultant’s education, coordination of care and education to the participant will be provided. In more cases than not, this will contribute to an appropriate treatment plan, fewer medical fees through patient education and negotiated equipment and care costs.

For Case Summaries of how Medical Case Management has preserved benefits for the client and account, please follow the links below;

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