Workflow — Workers' Comp Medical Review

WC peer review without the per-review vendor markup.

Injury reports, treating-provider notes, IME reports, prior treatment history → causation analysis, treatment-plan compliance with state guidelines (ODG, ACOEM), MMI (Maximum Medical Improvement) determination, impairment rating. Utilization-review decision and peer-review report into the claims system. Replaces peer-review vendor labor at Genex, Medata, Mitchell Medical Management at a fraction of the per-review cost.

Take the AI Assessment Get a Per-Review ROI Model

$75–$400

Per review at Genex, Medata, Mitchell Medical Mgmt

ODG / ACOEM

State-recognized treatment-guideline references

60–85%

Routine review off the peer-review-vendor line after AI cutover

What This Replaces

The Peer-Review Vendor on Every WC Treatment Decision

The work the peer-review vendor does on every WC medical review — and the cost of leaving it there.

The labor

Workers' comp medical record review today moves through peer-review vendors — Genex (now part of Mitchell), Medata, Mitchell Medical Management, plus other state-licensed peer-review companies. Per-review cost runs $75–$400 depending on review type (utilization review, peer-to-peer review, IME, MMI assessment, impairment rating). A regional WC carrier or TPA with sustained claim volume routinely runs into seven figures of peer-review vendor spend annually.

The cycle time

Standard WC peer-review cycle runs 5–15 business days from request to report at the peer-review vendor, with longer cycles when the case requires multi-specialty review (e.g., orthopedic plus pain management) or when state-specific UR timelines compress the cycle. State-specific WC UR-timeliness rules (typically 3–10 business days depending on the state) create deadline pressure, and missed UR deadlines can trigger automatic approval of treatment regardless of medical-necessity findings.

The Workflow

Input · Analysis · Output

What goes into WC review, what we do to it, and what shows up in the claims system.

Input

Injury history + treatment + IME

First report of injury (FROI) and SROI updates
Treating-provider notes and orders
IME (independent medical examination) reports
Prior treatment history per the claim
Diagnostic imaging and lab reports
State-specific WC treatment guideline references (ODG, ACOEM)
Prior UR and peer-review history per claim

Analysis

Causation, compliance, MMI

Causation analysis (work-relatedness, apportionment)
Treatment-plan compliance vs ODG / ACOEM guidelines
MMI (Maximum Medical Improvement) determination
Impairment rating per AMA Guides edition
Utilization-review decision (approve / modify / deny)
Peer-to-peer-review readiness packaging
Confidence score per finding; exceptions to physician-reviewer queue

Output

Review report into the claims system

Utilization-review decision report
Peer-review report with the basis cited
Claims-system update (Guidewire ClaimCenter, Duck Creek, Origami)
WC-bill-review workflow handoff (where applicable)
State WC-bureau report (where required)
Per-review audit trail with guideline-citation basis
UR-timeliness tracking dashboard

Side by Side

WC Medical Review Today vs. With Last Rev

The numbers that matter: cycle time, per-review cost, accuracy, and UR-timeliness compliance.

Dimension	Peer-Review Vendor (Genex / Medata / Mitchell)	Last Rev WC Medical Review
Cycle time, request to peer-review report	5–15 business days at peer-review vendor	1–4 hours per review
Per-review unit cost	$75–$400 per review	Per-review, benchmarked at 25–45% of vendor unit cost
State UR-timeliness compliance	At-risk on volume spikes	Cycle time dramatically inside state UR windows
ODG / ACOEM compliance consistency	Variable — vendor reviewer judgment, drift across teams	ODG / ACOEM citations applied identically per review
MMI / impairment-rating consistency	Per-AMA-Guides-edition drift across reviewers	AMA Guides edition applied per state with citation per element
Claims-system integration	Vendor portal handoff, manual claims-system update	Direct via documented Guidewire / Duck Creek / Origami APIs
Audit log per finding	Vendor reviewer notes, no per-citation lineage	Source medical record + guideline citation + AMA Guides edition + confidence per element

How It Works

From Treatment Request to Peer-Review Report

Five steps. Every one logged. Every one reversible if your confidence threshold isn't met.

Submission Lands

First report of injury (FROI) and SROI updates, treating-provider notes and orders, IME reports, prior treatment history per the claim, diagnostic imaging and lab reports — paired with state-specific WC treatment guideline references (ODG, ACOEM) and prior UR / peer-review history per claim.

Extraction & Classification

Causation analysis (work-relatedness, apportionment). Treatment-plan compliance vs ODG / ACOEM guidelines. MMI (Maximum Medical Improvement) determination. Impairment rating per the relevant AMA Guides edition (per state). Utilization-review decision (approve / modify / deny). Peer-to-peer-review readiness packaging.

Validation Against Guidelines and State Bar

Findings validated against ODG (Official Disability Guidelines), ACOEM treatment guidelines, AMA Guides per state, and the carrier's WC playbook. Anything below your confidence threshold per finding is routed to the physician-reviewer queue — final clinical determination remains with the regulated entity (utilization-review physician or designated peer reviewer).

Push to Claims System

Utilization-review decision report and peer-review report with the basis cited into Guidewire ClaimCenter, Duck Creek, or Origami via the documented integration. WC-bill-review workflow handoff (where applicable). State WC-bureau report (where required). UR-timeliness tracking dashboard updated.

Audit Log Persisted

Every causation analysis, treatment-plan-compliance citation, MMI / impairment-rating finding, and UR decision logged with the source medical record, guideline citation, AMA Guides edition, model version, and confidence score. State WC-bureau-audit-ready and yours.

Compliance & Defensibility

Built to Meet the Quality Bar WC Operations Already Run On

ODG / ACOEM / AMA Guides conformance

Official Disability Guidelines (ODG), ACOEM treatment guidelines, and AMA Guides to the Evaluation of Permanent Impairment (per state-required edition) tracked. Per-state guideline-version preserved in the audit log so WC-bureau audits resolve cleanly.

State WC bureau and DOI posture

Per-state UR timeliness, WC-bureau reporting, and DOI-required peer-review credentials respected. Per-state rules update flow into the validation engine within days of effective dates.

No clinical-determination authority

We don't make the final UR or peer-review determination. We assemble the medical evidence, apply ODG / ACOEM / AMA Guides analysis, and draft the report; the utilization-review physician or designated peer reviewer reviews, edits, and signs off. The reviewer is in the review-and-approve loop on every report.

PHI / HIPAA / 42 CFR Part 2 posture

WC medical record data contains PHI under HIPAA plus substance-use information under 42 CFR Part 2 in some cases. Deployable in your VPC or our SOC 2 / HIPAA-aware environment. Encryption in transit and at rest; retention policies tied to your state WC-bureau recordkeeping rules and HIPAA recordkeeping.

Common Questions

What WC Carriers and TPAs Ask About Medical Record Review

Those are the peer-review vendors that run the work today at $75–$400 per review on a per-event pricing model. We're not a peer-review vendor — we integrate directly into your existing claims system, undercut the per-review labor cost, and deliver UR / peer-review reports for licensed-physician-reviewer sign-off. The licensed-reviewer role under state WC rules remains with the regulated entity.

We don't replace the licensed peer reviewer. State WC rules require licensed-physician sign-off on UR decisions and peer-review reports. We assemble the medical evidence, apply ODG / ACOEM / AMA Guides analysis, and draft the report; the licensed reviewer signs off. The licensed reviewer is in the review-and-approve loop on every report.

Our pilot success threshold is causation, ODG / ACOEM treatment-compliance, MMI, and impairment-rating accuracy at parity with or above your incumbent peer-review process, measured on the same shadow-data sample of historical reviews. Anything below your defined confidence threshold per finding is routed to the physician-reviewer review queue — your call which queue, ours or yours.

ODG, ACOEM, and AMA Guides are encoded as configurable rule sets per state. Per-state guideline-version preserved in the audit log so WC-bureau audits resolve cleanly. Updates to guideline editions flow into the validation engine within days of effective dates.

Per-state UR-timeliness rules (typically 3–10 business days depending on the state) are tracked per review as workflow SLAs. Aging reviews surface for proactive physician-reviewer action before UR windows close. The audit log records every timing milestone supporting WC-bureau audits.

Yes — through the documented integration surface each platform supports. Guidewire via ClaimCenter REST or EDGE; Duck Creek via OnDemand APIs; Origami Risk via the REST API. Peer-review-vendor handoff via documented integration patterns where APIs exist; fallback to PDF / fax where they do not. Your IT, clinical, and claims teams review and approve service accounts. We do not require platform-side custom development.

WC medical-review pilots typically run 6–8 weeks: 1–2 weeks of integration and per-state guideline mapping with the WC clinical team, 4 weeks of shadow-mode running on real reviews with no claims-side decisions, 1–2 weeks of supervised cutover on a constrained scope (one state, one injury type). Production rollout is staged after the pilot meets your accuracy and clinical-management sign-off.

We benchmark against your current per-review cost — typically $75–$400 at peer-review vendors. Our target is 25–45% of that per-review cost at higher accuracy and faster cycle time. Pricing structures around volume tiers and outcome SLAs (UR-timeliness compliance), not per-review event pricing.

Two Ways to Start

Take the AI assessment for a structured read on WC medical-review feasibility. Or talk to us if you already know peer-review vendor cost is the largest line on your WC clinical-operations budget.

Self-serve · 8 minutes

Take the AI Assessment

A short structured assessment that maps your monthly review volume, claims system, and current peer-review-vendor arrangement to AI feasibility and ROI.

Talk to a specialist

Get a Per-Review ROI Model

Send us your monthly review volume, your claims system, and your current peer-review-vendor arrangement. We'll come back with a per-review unit-cost comparison and a 6–8 week pilot plan in 5 business days.

Other Workflows

More Healthcare Admin Workflows We Replace

The same approach, applied to the other document-heavy labor lines on your healthcare-admin budget.

WC Medical Bill Review

CMS-1500, UB-04 → fee-schedule compliance, duplicates, treatment-plan check.

Disability Determination

SSDI / SSI medical evidence → SSA Listings or RFC assessment, decision rationale drafted.

Clinical Denial Appeal

Denial letters and medical records → payer-policy-cited appeal letters with evidence chronology.

Prior Authorization

Physician orders + clinical notes → InterQual / MCG match, payer-portal submission, status tracking.