Posted: 4/24/2018

One of the many complaints physician advisors have about managed care organizations (MCOs) is payment denials based on inappropriate use of admission screening criteria.

The two predominant sets of criteria, MCG and InterQual, differ in many ways but they have one thing in common: They are both clinical screening criteria that are used to recommend the medical necessity and proper setting for care – in this case whether outpatient with observation or inpatient status is appropriate. Both allow for second level review when the published criteria don’t support admission but a physician determines that inpatient care is appropriate based on complex medical judgment. In practice, MCG and InterQual reviews are a 2-step process: a case manager generally reviews a case first using the criteria, and then, if criteria aren’t met, a physician advisor may be asked to review it.

In other words, screening criteria screen for admission but failure to meet these criteria shouldn’t be used as the sole argument against admission. In fact, when doing secondary reviews, physician advisors don’t refer to the criteria.

Physician advisors are often frustrated, however when medical directors at MCOs say they are following InterQual or MCG and quote the published criteria in denying payment for inpatient admissions but refuse to allow for physician judgment. I have wondered why, if all they are doing is quoting the same narrowly defined objective criteria that nurse case managers use, there are physician medical directors at these plans at all. A peer-to-peer discussion is supposed to be between physicians, not a physician and a set of published screening criteria. As I maintained in a prior ACPA blog post on this subject (see “Use and Abuse of Screening Criteria”, ACPA Blog, 8/30/2016), “secondary review is an integral part of both criteria sets but is often conveniently ignored when a payer wants to deny payment.”

If medical directors are going to misuse criteria and fail to listen to physician advisors or treating physicians, I felt I needed to consult a higher power, so I contacted Dr. William Rifkin, Managing Editor and Physician Relations Specialist at MCG and asked him his approach to this issue.

Dr. Rifkin began his response by quoting from the MCG guidelines:

“The care guidelines are designed to assist the clinical review process that is needed to render judgment about as to when admission or a procedure may be appropriate. There may be occasions when admission or a procedure is necessary even when the indications listed are not present. The guidelines are not inflexible expectations for all patients but should be considered as guidelines to quality care. The care guidelines are not designed to be used in isolation, but rather in conjunction with clinical judgment.” (Emphasis added.)

Dr. Rifkin explained, ”The guidelines are not intended as a substitute for professional judgment. Use of the care guidelines without proper consideration of the unique characteristics of each patient is an inappropriate use of the care guidelines.” As an example, Dr. Rifkin mentioned the difficulty in using a criteria set that includes tachycardia for a patient on a Beta-blocker, which prevents the heart rate from increasing. And if a guideline requires a heart rate of 100 or more, the difference between a heart rate of 99 and 101 should never be a reason for a denial. To a physician, there is no difference between a heart rate of 99 and 101, yet that small difference in documentation could mean not meeting inpatient criteria.

“We use numbers drawn from well-respected sources,” Dr. Rifkin wrote, “but the numbers we use are not unanimously agreed upon.”

On the other hand, Dr. Rifkin warned that physicians should not think that they can “self-define what is sick, unstable or severe”. The archaic attitude of ”I’m the doctor, I’ve seen the patient, and it’s my license, and judgment, so therefore, if I say inpatient care is needed, that is the case” would be an inappropriate (and losing) argument. By the same token, a physician should not say, “My definition of tachycardia is 80.”

“So it goes both ways,” he elaborated. “Yes, clinical judgment is necessary and an opportunity should be afforded to explain oneself but at the same time clinical judgment and point of view needs to be rational, coherent, clinically correct and defendable.”

And there you have it: According to the managing editor at MCG, the physician should be allowed to make a case for inpatient admission when the guidelines don’t tell the whole story, but it isn’t OK to be fanciful and “make stuff up” (my words). If the whole clinical picture says inpatient but the guidelines say “not so fast”, the medical director should be willing to listen to a solid clinical discussion and not hide behind a denial based on “criteria”.

Fortunately for those attending the Physician Advisors Conference/ SEPAS 2018 in Greenville, SC on April 30 to May 2, Dr. Rifkin will be a featured speaker.

Look for a future blog with InterQual’s take on this important issue.

Thanks to Dr. Rifkin for contributing to this article.