A quiet shift that could shake up hospital Utilization Review

There is a seismic shift happening in Utilization Review: As of Saturday, May 1, 2021, UnitedHealthcare, the country’s largest healthcare insurance provider, is changing guidelines to adjudicate the level of care cases for hospitals from Milliman Care Guidelines (MCG) to InterQual.1 AppriseMD will be working closely with our current hospital clients to ensure this is a smooth transition. And though this shift will have widespread impact for hospitals across the country, it is happening quietly.

The shift is significant because of significant differences between the guidelines. There is also uncertainty as to how UnitedHealthcare is going to review cases using these new guidelines. “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,” according to a Q&A published by HealthLeaders Media.2

“Nobody’s talking about the guidelines and the criteria for inpatient or observation level of care, which plays a major role in hospital admissions, denials and ultimately reimbursement,” said Dr. Franklin Baumann, CEO of AppriseMD and a former medical director with UnitedHealthcare.

According to Healthcare Legal Solutions, “While UHC framed its decision as a response to provider requests, it coincides with the recent purchase of Change Healthcare, which maintains the InterQual Criteria, by Optum, the healthcare analytics company owned by UHC’s parent company, UnitedHealth Group. UHC has a history of applying Optum products to its plans, such as its use of Optum’s Emergency Department Claim (EDC) Analyzer tool to downcode and deny ED claims.”3

“The impact of UHC’s change on CM denials remains to be seen. InterQual’s criteria are, in some respects, stricter than Milliman’s, with more precise clinical benchmarks for each level of care. That could mean an uptick in denials for cases in which the patient is borderline for inpatient vs. observation or discharge vs. continued stay. At the same time, UHC has a track record of denying admissions that clearly meet MCG, so we can’t expect InterQual to act as a check on their denials. Providers must keep up the pressure on UHC and other payers that issue wrongful denials.”2

“We will be watching closely to see how this change impacts hospitals and utilization review teams,” Dr. Baumann said. “Having worked on both the medical side and the insurance side of healthcare, I have seen so many instances where payers say they follow national evidence-based guidelines but then don’t. Everyone needs more information about this change and an increased level of diligence when it comes to reviews, the peer-to-peer process and appeals.”

  1. UnitedHealthcare, “Reminder: We’re transitioning to InterQual®, effective May 1” https://www.uhcprovider.com/en/resource-library/news/featured-news-2021/interqual-clinical-criteria.html
  2. HealthLeaders Media, “Q&A: New UnitedHealthcare Guidelines, Analysis” March 03, 2021. https://www.healthleadersmedia.com/revenue-cycle/qa-new-unitedhealthcare-guidelines
  3. Healthcare Legal Solutions, LLS, “UnitedHealthcare Switch from Milliman to InterQual,” https://hlsllc.com/news/united-healthcare-to-switch-from-milliman-to-interqual/
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