Clinical Experience
Interpret diagnoses, physiology, treatment decisions, complications and response to care in the context of the individual patient.
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The Physicians Behind the ReviewExperienced physicians. Independent clinical judgment.
Behind every complex review is a physician responsible for understanding the clinical record, applying the appropriate review framework and explaining the clinical determination clearly.
What our physicians bring
A physician reviews the case—not an algorithm.
Clinical decision-support tools can organize information. Complex medical-necessity cases still require physician interpretation of the patient, documentation, treatment course and applicable framework.
Independent Judgment
Follow the documented clinical facts and reach the determination supported by the record rather than a predetermined outcome.
UM Expertise
Understand how clinical medicine intersects with medical necessity, level of care, coverage frameworks and operational workflows.
Clear Communication
Translate a complex medical record into a focused rationale identifying the facts that materially affected the determination.
From medical record to clinical determination
1. Understand the presentation
Why did the patient require evaluation or treatment, and what was known at the relevant decision point?
2. Assess severity and intensity
What physiologic abnormalities, treatments, monitoring requirements, complications and risks were present?
3. Follow the clinical trajectory
Did the patient improve, deteriorate, develop a complication, or become ready for transition to a lower level of care?
4. Apply the authorized framework
Relevant coverage requirements and appropriately licensed or authorized clinical criteria guide the review when applicable.
5. Make and explain the determination
The physician integrates the complete record and applicable framework, then communicates the clinical factors that materially drive the decision.
Criteria guide the review process. Physicians make the clinical determination.
Pankaj Karan, M.D., ABIM
Founder and Medical Director
Dr. Pankaj Karan leads UM Physician Advisors LLC with a physician-first approach to utilization management: understand the complete clinical record, apply the appropriate review framework, and document the reasoning clearly.
His work focuses on physician-level medical necessity and level-of-care review for healthcare organizations, including inpatient and observation review, continued stay, retrospective review, appeals, peer-to-peer discussions and complex case escalation.
The diagnosis starts the review.
The clinical course tells the story.
Physician judgment completes the determination.Need physician review capacity?
Discuss ongoing coverage, overflow reviews, appeals, or a customized UM program.