“We will use InterQual and Milliman as screening tools, as guides,” said Andrea Banko of HDI, covering Region D, Jones reported. “We will use InterQual,” stated Mary Hoffman, representing CGI in Region B. David Yin, the project manager for DCS in Region A, said his organization would be using Milliman, the announcement of which induced a string of exclamation marks from Jones. Christine Costelli, a principal of Connolly Consulting, was quoted as saying “we have not decided which clinical standards we will use.”

 

Fast forward to May 25, when Connolly notified providers that “…as of today, Connolly will be using Milliman.”

 

The risk to providers reviewed by a RAC using a different set of criteria to make judgments on medical necessity – including determinations citing lack of documentation to support medical necessity, particularly for inpatient vs. outpatient settings – is simply too huge not to be closely examined, too important to be dismissed as some providers now are tempted to do, according to Ernie de los Santos of eduTrax who is working on an upcoming article for RACMonitor.com that will appear next week.

 

Santos interviewed a provider’s compliance officer who told him a few days after Connolly’s announcement “…I still am afraid that we are admitting too many one-day stays even though they are meeting InterQual criteria. …Connolly’s choice of Milliman makes us a little nervous.

 

You’ll read in the upcoming article why Connolly chose Milliman alone instead of using InterQual, or both. A second article by Patricia Dear, RN and president of eduTrax, will provide a compare-and-contrast overview by looking at something as common as chest pain under both sets of guidelines.

 

Finally, a RAC University LIVE Webinar will follow shortly thereafter, showing more specifics about what kind of trouble might arise when a facility is using InterQual and a RAC is using Milliman. Stay tuned for the schedule.

 

Please feel free to join the conversation. Send me an e-mail and let us know your point of view. What might your facility already have done in light of this development? How have your physicians responded to the RACs? And have you received any RAC record requests or even denials yet? If so, for what are they asking?

 

Plus we’d like to hear what you want to see from us – topics to cover, questions to answer, etc., so we can share this experience with others.

 

Thanks for your support.

 

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