In a bulletin posted February 1, UnitedHealthcare (UHC) announced that "We will transition to InterQual criteria for all benefit plans effective May 1, 2021." Although not specified in the announcement, the implication is that the change will apply to dates of services on or after May 1, 2021.
UHC, which currently uses the Milliman Care Guidelines (MCG) to review inpatient admissions for level of care and length of stay, is, for many hospital care management (CM) departments, one of the top-denying payers.
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.
Even after UHC's switch, many payers will continue to use MCG. Among them: Aetna, which operates Medicare, Medicaid, and commercial plans across the country; Anthem, which operates BlueCross BlueShield plans as well as Amerigroup managed care plans; and Kaiser Permanente.
InterQual is a popular choice among Medicaid MCO plans. In Maryland, InterQual is used by the Johns Hopkins Healthcare family of plans, which includes Priority Partners, as well as Maryland Physicians Care, Jai Medical Systems, and MedStar Family Choice. InterQual is also the choice of payers that offer MCO plans in others states, including AmeriHealth, Centene, and Molina.
In addition to Milliman and InterQual, many payers maintain their own medical necessity policies. They may also make custom add-ons to Milliman and InterQual, so their versions of the guidelines may differ from the off-the-shelf product that hospitals purchase. Notably, the Centers for Medicare and Medicaid Services (CMS), has declined to adopt a proprietary decision support tool like Milliman or InterQual, hewing instead to a broader definition of medical necessity.
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.
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