Unabashedly, this is a teaser for an upcoming webinar “How to Outflank Capricious and Arbitrary Medical Necessity Guidelines from Payers” – a deep-dive look to the role and relevance of these two national standards for guiding a hospital’s utilization and denial management efforts.  There’s much to unpack, especially for nurses and physicians new to UM.

In March a Connecticut US District Court judge ruled in Alexander v. Azar that over-reliance on MCG and InterQual created the basis for granting appeal rights to a class of patients hospitalized under observation.  Certain patients hospitalized under observation may have had their due process rights violated by applying MCG and InterQual in admission status decisions. (You can read my RAC Monitor piece on the death of national standards).  So, what role can we expect these national standards to play?

When it comes which product, MCG or InterQual is best, I have friends on both sides, including some involved in product development.  Each product had their unique beginnings and purposes.  Put head-to-head, however, and there’s a problem.  You would expect few differences except for nifty features, but not substantial content differences.

Those of us with hands-on experience in fighting or avoiding denials can attest that MCG is the hands-down favorite of payers.  This begs the question of why (nifty features, coming up!).  I have theorized that it’s because MCG allows its proprietary content to be modified in ways we providers are not privy.  Ok, I’ve said it in much stronger terms in this forum and others; and it’s not a theory if payer denial letters and MCG sales people are to be believed.  Please ignore the paradox in that statement, but we have to start somewhere.

There are other factors such as plain misuse, such as applying critical care criteria to a medical unit patient.  There’s a lack of transparency and attention to detail in the application of MCG by payer medical directors.  MCG is not to blame for these.  Yet there is still the issue of what to trust.

Can MCG and InterQual serve as reasonable tools for determining initial status?  Only if you like leaving money on the table by starting every hospitalization as observation and see no problem with 4 day observation stays.  Can they be useful in keeping us honest? Only if you believe the playing field is level.  Drive practice in a way most advantageous to patient outcomes?  That’s a question of evidenced based practice.  MCG in particular wants us to accept that following their guidelines leads to better outcomes.  That’s a subject for clinicians to debate.  There is for UM nurses and physician advisors one nagging question: since when did a one size fit all?

Those steeped in the study of social determinates of health (SDoH) know that recovery curves and severity of illness directly correlate to social and economic inequities.  When a national UM standard sets aggressive recovery timelines, many SDoH challenged patients are left in the cold (and providers punished for caring).  It’s akin to clinical trials of an antihypertensive only on middle-aged white men in the Ukraine where genetic diversity is not what you will find in multiethnic populations such as in the US.  I am not making up this scenario.

What about appeals? Neither MCG nor InterQual ever won me an appeal.  As such MCG and InterQual are weak bases for CDI development.  Appeals are won on good clinical documentation.  Claims paid, the result of good coding based on ICD 10 informed documentation, will always provide the best guidance for CDI initiatives.

UHC may have decided to abandon both altogether.  Expect others to follow suit.  A recent denial of coverage from UHC mentioned neither national standard instead citing internal medical necessity indicators.  It was overcome because the denial was not based on anything factual – that is anything in the medical record.  I received a call today from a HealthNet UM nurse who was unable to access our records remotely.  Had she not been thoughtful enough to call (stepping out of protocol) the case would go straight to a medical director without any clinical documentation whatsoever.

On the basis of which national standard would such a case be denied? I guarantee that the denial letter would have quoted an MCG guideline.  Just saying, “We received nothing” would be better, as that recent court case suggests.

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