UnitedHealthcare’s Observation Utilization Review Guide is sunsetting and will be replaced by the new Hospital Services: Observation and Inpatient Policy1. The change takes effect Dec. 1, 2022, for commercial, community and exchange plans.
The new policy explicitly mentions InterQual, stating “InterQual criteria are intended to be used in connection with the independent professional medical judgment of a qualified health care provider.” While this is new, it is not likely to result in any positive or negative changes to a hospital or its patients as UHC has been using InterQual as part of its utilization management process since May 1, 2021.
There are six new diagnoses listed in the policy, which UHC says “an observation level of care is often used to manage.” The new diagnoses are:
- Anemia
- Atrial Fibrillation
- COPD
- CHF
- Pneumonia
- Weakness
These diagnoses have historically result in an observation level of care. The biggest issue with this expanded list, from the utilization review standpoint, is that the UHC utilization review nurse managers may flag more of these diagnoses for a closer review by medical directors rather than allowing at a higher level of care. It is therefore important for hospitals to pay close attention to the documentation for these diagnosis proactively because this increased scrutiny will likely lead to more denials.
The new policy states, “If the member’s condition does not improve within 48 hours, additional clinical information should be submitted to support an inpatient level of care.” This is not found in the old policy. It may be that a hospital’s utilization management staff already routinely do this. However, if they do not, it should become a routine practice. The additional submission may be an opportunity to provide more information directly to UHC and potentially avoid a denial and the need for a reconsideration Peer-to-Peer discussion and/or formal appeal.
How the new Hospital Services: Observation and Inpatient Policy will impact UHC’s day-to-day determinations remains to be seen. For this reason, being aware of these changes allows hospitals to make helpful adjustments in advance. UM departments and physician advisors should continue to monitor cases and denials as the change is implemented.
SOURCES
- United Healthcare, Hospital Services: Observation and Inpatient, Policy Number: 2022T0643A
- United Healthcare, Observation Services Utilization Review Guideline