The United States Department of Justice filed an antitrust lawsuit earlier this year aiming to stop UnitedHealth Group from acquiring Change Healthcare.1 Hospital CFOs and utilization review managers have much to watch in this case related to how it could not only impact competition in the markets but how it could impact the guidelines used to adjudicate level of care cases.
The Justice Department’s antitrust lawsuit argues the merger of UnitedHealth and Change “would harm competition in commercial health insurance markets, as well as in the market for a vital technology used by health insurers to process health insurance claims and reduce health care costs.”1 Five months after announcing the deal to acquire Change, UnitedHealth changed its guidelines to adjudicate the level of care cases for hospitals from Milliman Care Guidelines (MCG) to InterQual. InterQual Criteria is maintained by Change.
“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 impacts hospitals and utilization review teams,” said Franklin E Baumann, MD, CEO of AppriseMD. “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 how UnitedHealth will handle claims and an increased level of diligence when it comes to reviews, the peer-to-peer process and appeals.”
The focus of the Justice Department is clearly on the revenue cycle as noted in its recent statement , “The proposed transaction threatens an inflection point in the health care industry by giving United control of a critical data highway through which about half of all Americans’ health insurance claims pass each year.”1For those involved in hospital utilization management, the final fate of InterQual is just as important.
- United States Department of Justice, “Justice Department Sues to Block UnitedHealth Group’s Acquisition of Change Healthcare,” February 24, 2022. https://www.justice.gov/opa/pr/justice-department-sues-block-unitedhealth-group-s-acquisition-change-healthcare
- HealthLeaders Media, “Q&A: New UnitedHealthcare Guidelines, Analysis” March 03, 2021. https://www.healthleadersmedia.com/revenue-cycle/qa-new-unitedhealthcare-guidelines
Mathews, Anna Wilde, and Kendall Brent, Wall Street Journal, “Justice Department Sues to Block UnitedHealth’s Planned Buy of Change Healthcare” February 24, 2022