InterQual® vs. Milliman Care Guidelines

On May 1, 2021, UnitedHealthcare (UHC) will transition its utilization management approach for all its health plans from Milliman Care Guidelines (MCG) to InterQual® criteria.

That means, going forward, every hospital contracted with UHC without access to InterQual will need to determine how to evaluate admission status and medical necessity for services.

A Closer Look: Definition And Use

Let’s first address the purpose of InterQual and MCG. Healthcare providers and payers use these guidelines to assist in medical necessity determinations for appropriate level of care and admission status (inpatient vs. observation), inpatient length of stay, and medical necessity for outpatient services, such as diagnostic tests and surgeries.

Both products are evidence-based clinical criteria, and both products assist in determining whether it is medically necessary for a patient to be admitted to the hospital. Medical Necessity for Inpatient level of care is based on two factors: Severity of Illness and Intensity of Service.

  1. Severity of Illness, as it implies, addresses the severity of a patient’s condition. Factors affecting this determination include abnormal lab or test results, abnormal physical assessment findings risk factors, comorbid conditions, and risk of mortality.

  2. Intensity of Service addresses the treatment plan. Treatments to support Inpatient level of care are those treatments that cannot be performed safely in an outpatient or home setting. Treatments such as intravenous (IV) medications (IV antibiotics), IV pain meds, or other medication to control symptoms), frequency of IV medications for symptom control, telemetry monitoring, close monitoring with special assessments (such as neurological assessments), monitoring for and/or treating side effects, etc. Inpatient treatments also include urgent surgeries and interventions that cannot be performed as an outpatient or at home.

While both guidelines use Severity of Illness and Intensity of Service to reach a determination, the primary difference between the two approaches is the emphasis each set of guidelines places on the two factors. MCG focuses more on severity of illness and diagnosis. InterQual focuses more on intensity of service required and provides detailed day-by-day guidelines.

Keep in mind, both MCG and InterQual provide “guidelines” only, and these guidelines do not substitute a physicians’ professional judgment and other factors when determining medical necessity. In addition, it is important to note that CMS (Centers for Medicare and Medicaid Services) does not endorse Interqual, MCG, or any other particular set of criteria.

Your Questions, Answered

Now what? At Advicare, we regularly hear questions from our hospital and health systems about this switch and what it might mean to their operations and their admission decision making, as well as whether or not they will see more or less clinical denials. Specifically, our clients most frequently ask the following questions:

1. How will this change in criteria impact admissions for patients with UHC insurance if the hospital does not utilize InterQual?

Whether a hospital uses InterQual or MCG, the change should have minimal impact. Remember, both criteria platforms only serve as guidelines. The key to preventing clinical denials on medical necessity grounds is documentation by the physician. Physician documentation needs to be objective and detailed, providing specific information to support both severity of illness and intensity of service. Moreover, the documentation should support the physician’s judgment and identify comorbidities as well as risk factors.

2. What is the difference between the InterQual® criteria and MCG?

As we described above, both guidelines evaluate severity of illness and intensity of service to help hospitals make an inpatient admission determination. However, MCG puts more emphasis on the patient’s severity of illness. And InterQual addresses both severity of illness and intensity of service, but it puts additional emphasis on the intensity of service required based on the patient’s condition.

There is no definitive rationale as to why one group leans one way versus the other, but we do have our own observations about the two sets of criteria. In our opinion, the criteria set out in MCG is less precise, leaving room for interpretation. On the other hand, InterQual is very specific and detailed in setting criteria for both severity of illness (citing precise vital sign abnormalities, lab values, test results, etc.) and intensity of service (specific treatments/treatment plan that must be done) to meet inpatient level of care.

Looking At The Bigger Picture

Regardless of which criteria your hospital uses, there is no substitute for clear, complete, and timely clinical documentation. When the documentation reflects a true picture of the patient’s diagnosis, the patient’s care for that condition, and the quality of that care, it reduces ambiguity as to the level of care required for that particular patient.

Are you interested in exploring how the transition to InterQual will affect your organization? To explore solutions and further examine your hospital’s approach to overturning clinical denials and denial prevention, contact us today.