Posted: 7/26/2018

I have written several articles on one of my pet peeves (and likely one of yours): the manner in which some managed care and government reviewers deny inpatient admission/payment based on failure to meet screening criteria while failing to allow secondary review by a physician to override objective criteria.

Application of InterQual and MCG criteria is a 2-step process when a case fails to meet screening criteria, which are generally applied by nurse case managers who compare a patient's clinical presentation to published criteria for admission. Although each case is unique, these criteria are often very specific and case managers are not allowed to make exceptions. This is where the physician advisor comes in. A patient that "fails criteria" but can be admitted following physician advisor review would be a false negative review. The physician advisor applies "complex medical judgment" (Medicare's term) and by reviewing the entire case can recommend admission when printed criteria aren't met. When auditors insist on "going by the book" and refuse to listen to a physician's argument for inpatient admission, they are not following proper review process.

On April 24, 2018 I published “Use and abuse of admission criteria” on the ACPA blog. In that article I said that secondary review “is an integral part of both [InterQual and MCG] criteria sets but is often conveniently ignored when a payer wants to deny payment.” (See https://tinyurl.com/y6uptbvf.)

In my April 24, 2018 ACPA blog post, “Push back against abuse of admission criteria” I focused on MCG and published comments from Dr. William Rifkin, Managing Editor and Physician Relations Specialist at MCG, who wrote, “The care guidelines are not designed to be used in isolation, but rather in conjunction with clinical judgment…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.” (Read that article here: https://tinyurl.com/yd2ejy2x.)

As I promised, I have asked Dr. Steven Silverstein, Vice President and Chief Clinical Architect of Decision Support at Change Healthcare, the publisher of the InterQual Guidelines (it’s no longer published by McKesson) to answer the same question that I put to Dr. Rifkin:

"Can you please comment on the practice of managed care medical directors denying payment for inpatient care because a patient didn't meet objective InterQual criteria and not allowing a physician to present a complex clinical argument in support of admission? Is this an appropriate use of InterQual Guidelines?”

Here is his response (published with his consent):

Dr. Silverstein began by quoting an excerpt from the InterQual Acute Level of Care Review Process monograph:

“It is important to understand that “the Criteria reflect clinical interpretations and analyses and cannot alone either resolve medical ambiguities of particular situations or provide the sole basis for definitive decisions. The Criteria are intended solely for use as screening guidelines with respect to the medical appropriateness of healthcare services and not for final clinical or payment determinations concerning the type or level of medical care provided, or proposed to be provided, to a patient.”

Dr. Silverstein explained further,

"The criteria, if not met, are not the end of the discussion but serve to initiate the conversation between payor and provider. The concept of Secondary Review is an integral element in the appropriate use of InterQual criteria and is a necessary step in the final determination of the need for hospital admission or continued stay." (emphasis added)

Dr. Silverstein emphasized the critical importance of secondary review; it cannot be excised from the review process: “Secondary Review,” he emphasized, “is essential when criteria are not met and is clearly outlined as a required step in the Review Process.”

"Secondary review uses criteria as a starting point to frame the discussion, and more importantly takes into account additional clinical information and the clinical judgment of the attending physician or physician advisor. Using that additional information and judgment as part of a peer-to-peer meeting or a formal appeal is entirely appropriate in order to make a final determination of medical necessity."

I hope you find Dr. Silverstein and Dr. Rifkin’s comments helpful in your internal review process and that you can use them to educate managed care medical directors if they deny payment based on MCG or InterQual criteria but refuse to allow physician judgment (secondary review) in determining the medical necessity of inpatient admission.

Also, keep in mind that passing InterQual review, with or without secondary review, doesn’t ensure meeting the 2-midnight rule for traditional Medicare patients nor does it mean that managed care plans will necessarily approve inpatient payment. But if a health plan says they are applying InterQual (or MCG) criteria and refuses to allow a physician to override the published criteria used by case managers in appropriate cases, go to the mat on your appeal.