Unabashedly, this is a teaser for an upcoming webinar offering a deep-dive look into the role and relevance of 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 utilization management (UM).

In March, a Connecticut U.S. District Court judge ruled in Alexander v. Azar that overreliance 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 when MCG and InterQual were applied in admission status decisions. (You can read my RACmonitor piece on the death of national standards). So, what role can we expect these national standards to play?

When it comes to which product, MCG or InterQual, is best, I have friends on both sides, including some involved in product development. Each product had its 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 payors. 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 to which 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 payor denial letters and MCG salespeople 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, or 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 payor 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 in observation status, and see no problem with four-day observation stays. Can they be useful in keeping us honest? Only if you believe that the playing field is level. Do they drive practice in a way most advantageous to patient outcomes? That’s a question of evidence-based practice. MCG in particular wants us to accept that following their guidelines leads to better outcomes, but that’s a subject for clinicians to debate. There is, for UM nurses and physician advisors, one nagging question, though: since when did one size fit all? 

Those steeped in the study of the social determinants 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 out 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 would find in multiethnic populations such as in the U.S. 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 clinical documentation improvement (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.    

UnitedHealthcare (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 have gone 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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