Q&A: New UnitedHealthcare guidelines

Q: As of May 1, UnitedHealthcare, the largest health insurance company in the United States, will be switching from using Milliman Care Guidelines (MCG) to InterQual. How will this affect organizations, and what can they do to smooth the transition?

A: While UnitedHealthcare will provide organizations with criteria to make status decisions for patients, it will not provide hospitals with the complete set of InterQual criteria, says Ronald Hirsch, MD, FACP, CHCQM, CHRI, vice president at R1 RCM Inc. Physician Advisory Solutions in Chicago.

For organizations that were using MCG, this creates a problem. “Every hospital that is contracted with UnitedHealthcare but does not have access to InterQual will need to discuss this change with their UnitedHealthcare representative to determine how cases will be reviewed,” says Hirsch.

The best advice for organizations, according to Colleen Morley, DNP, RN, CCM, CMAC, CMCN, ACM-RN, 2019–2021 president of CMSA Chicago, is to focus on ensuring that your organization is following best practices when it comes to utilization review. This includes:

• A thorough review process
• Solid documentation practices that provide reasoning and support for status decisions

And be prepared to defend status decisions, she says. Don’t back down if a case that clearly meets criteria is initially denied. “We see denials on cases that clearly meet any criteria set. If your documentation is good and supports medical necessity, stand up for it,” says Morley.

Also keep in mind that Medicare does not specify that hospitals must use a particular set of criteria. “It just states that patient stays must be reviewed for medical necessity,” Morley says.

For more on this topic, see the March issue of Case Management Monthly.