RACs and medical necessity criteria
Q: If my hospital is not using the latest InterQual criteria, could that chart be pulled by the RAC for fraud?
A: InterQual is merely a screening criteria—CMS doesn’t actually require hospitals to use it. Therefore, use of an older version or a different set of criteria such as Milliman is not inherently a problem. However, because outside entities such as RACs, MACs or QIOs will be reviewing cases, most hospitals choose to use the same version used by their contractors (presumably the version for the year applicable to the case). Additionally, outdated versions may not reflect advances in care and may cause inappropriate screening decisions.
Note that a patient may not meet InterQual inpatient criteria, but still be considered an inpatient upon physician review. InterQual is a screening criteria—it screens for the most likely inpatient and outpatient admissions, but can not take into account every medical circumstance. There are a percentage of patients, who will fail inpatient criteria due to factors not considered in the InterQual criteria that upon physician’s review will nevertheless be appropriate for inpatient admission.
For this reason, each permanent RAC will now have at least one physician medical director who will be involved in developing evidence for individual claims determinations and act as a resource for all reviewers making such individual claim determinations. Additionally, the provider has the opportunity to request that the medical director participate in discussions regarding individual claims denials.
In addition, RACs do not audit for fraud. Their only task is to look for overpayments and underpayments, either due to errors by the hospital or by CMS’ processing systems. RACs are simply looking for incorrect payments, no matter whose fault, and getting that money back to the Medicare Trust Fund after taking their cut. Of course, if a RAC believes it uncovers a fraudulent scheme or set of practices, it may make an appropriate referral to one of the contractors monitoring for fraud, but it is not a part of their scope of work.
Editor’s note: This question was answered by Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance for HCPro, Inc. It was originally published in The RAC Report, a bi-weekly HCPro e-newsletter.
It is also important to note that not all RACs will be using InterQual for claims investigations. HealthDataInsights, the RAC for 17 Western states, has declared it will be using Milliman Care Guidelines content and software to review Medicare claims. You can read more about that in a March 3 article published in Reuters.
Does your facility use InterQual, Milliman, or something different? Feel free to share your thoughts and experiences.
About the Author: Julie works in the case management market at HCPro, Inc. She works on all of HCPro’s product lines for case managers including books, audio conferences, journals, videos and an eNewsletter. To contact her with questions, comments, or to be a blog writer, email jmcginley@hcpro.com.
Mela Banks | May 29, 2009 | Reply
I am a director of case mgmt for a small rural hospital and our UR dept frequently comes across pts that do not fall perfectly into the screening criteria,yet the dr insists they need to be here. When we have those “gray area” pts, we try to work closely with the physician to ensure their documentation reflects exactly why the pt is in as inpt status. Depending on the day and the mood, sometimes we are listened to and sometimes we just don’t get what we need. I would like to know how other facilities handle the “gray” areas. Thanks
Robert Hodges, MSN, RN | May 29, 2009 | Reply
An active PA review process and UR committee will let you address those cases that fall into the “gray area”. They can work with providers to get the appropriate level of care ordered and override them if needed.
Another thing we did at my old home was to keep a copy of all the previous years InterQual books. It came in handy for late denials because they “didn’t meet criteria”. We could always review the case using the appropriate years criteria. Needless to say, we won most of those because we found denials were based on previous year criteria.
Mike Todai | May 29, 2009 | Reply
Mela:
In some cases, it may sound like physician Advisor [PA] is taking the attending physician’s side or most everything CM sends to PA is not listened to. This is a common complaint / issue.
There are a few short term and long term solutions. I do not have time to go over all the steps and no one suggestions will work for all the hospitals. It is possible that these steps have been taken and physician practice pattern has not changed.
Physician Advisor: I have learned that some physician advisors do not know how to use InterQual Guidelines. In all fairness I know of several PAs who do an excellent job. It would help to make sure that the PA you use does know how to use the book and apply it. Please do not assume that they do. Once they do know how to use the book, it helps them to educate the physicians how they may improve their documentation. It is easier to work with one or two physicians Advisors instead of talking to 40 to 400 physicians. Physician advisor can add their comments with their review to show why they agreed with the attending or why they do not feel patient status or continued stay is not justified. As we all know it that this may help somewhat in short run.
For example, a patient presents to ER. Lab value shows BUN 84 and Creat is 3.6. One of the diagnoses is Acute Renal Failure. A foley cath was placed but urine output was not documented. Patient was given IV fluid at 150 cc/hr. When you send this case to a case manager they know that this patient is sick. Chances are they will have difficulty to meet InterQual Guidelines/screen. CM will send it to the PA and he /she will approve it in less than 30 seconds. For a physician this is sick patient and should be an in-patient. They may question as to why the case manager does not get it. In order to use the lab value the way it is explained in this case.. it is important to have Oliguria or low urine output as per InterQual. I have witnessed firsthand with experienced and new case manager that they struggle with this. There are several other examples like this where it is appropriate for PA to approve a case as in-pt that case manager’s can’t use screening guidelines to justify in-pt.
Here if the PA knew how to use the guidelines then he/ she can help attending on what to document their findings and/or help case manager to understand the severity of Illness. We can find a way that is better than we vs. them.
Long term answer is to understand what physician is trying to do and why, Use critical clinical thinking to figure out the answers, be very good at knowing what the screening guidelines is and work with the physicians to get the documentation needed where appropriate. This is much easier said than done. It requires lot more than reviewing subset, SI & IS. It is more than seeing a green signal on a desk top if we are using such guidelines electronically. Some of the hospitals approve InterQal or other guidelines through MEC. At some of the hospitals. I do not find evidence of efforts being made to involve physician or in-service them about how to use it effectively and proactively. I have several physicians tell me that they do not know about this screening guidelines and case managers bring them up to when they are on the floor seeing their patients.
A case manager can do much better than saying to a physician that patient does not meet criteria. First of all it is setting a confrontational tone as per some attending physicians that a nurse is questioning their medical judgment.
Fortunately there are ways we can learn to do a better job including how we communicate to change the practice pattern. It takes time for the case managers to learn to do this effectively and make it easier for physicians to understand the documentation requirements. It helps to have support from Administration and Medical Leadership at the hospital. Most of the time this is done effectively one on one and working with the physician office Manager/ staff.
Loretta Olsen | Jun 1, 2009 | Reply
Julie,
It appears to me that HDI is going to use a combination of criteria tools, I heard from someone who attended one of the informational meetings held by HDI and they said they would be using Milliman, InterQual and Medicare. Do you suppose that in the article you referenced the source made an assumption that since HDI purchased the Milliman product that they would only be using Milliman?
Thanks
Loretta
Julie McGinley | Jun 2, 2009 | Reply
Loretta,
Thanks for pointing that out. The source I was quoting was the press release that stated that HDI purchased the Milliman software and would be using it for claims. It does not say they will use it exclusively, and I assume they won’t because reviewing claims probably takes several types of criteria, as you have mentioned. I only point this out because some facilities rely solely on InterQual criteria, when not all RACs will be using just InterQual criteria.
Steven Meyerson, MD | Jun 3, 2009 | Reply
One of the fundamental reason why it is so complicated and difficult to determine whether a patient should be admitted as an inpatient is that CMS has never defined what an inpatient is. They have a vague definition that states that a patient can be admitted if physician has determined that services have to be delivered in an inpatient setting but what is the difference between an observation unit and an inpatient bed when the same services are given in both? The disctinction is entirely arbitrary and even if the definition were clear, there are no rules to determine who is “sick enough” to need an inpatient bed. Is it really up to the admitting physician? I don’t think so.
We are left adrift in an “Alice in Wonderland” world of things that are not as they seem when along comes the Queen of Hearts(the RAC) who says, “Off with their heads” if hospitals did’t follow non-existent rules that CMS has refused to elaborate but the RAC is authorized to impose retroactively.
What a system!
Jane Arnold | Jun 5, 2009 | Reply
My facility has contracted with the following corporation for all cases that UR nurses cannot find criteria for patients to meet inpatient or observation status. The following was cut/pasted from their web site:
“Executive
Health Resources, Inc. (EHR),The Physician Advisor Company™, is the only company that provides hospitals with 7-day-a-week teams of specially-trained, technology-supported Physician Advisors focused on improving hospital clinical compliance and revenue integrity.”
Our mission is to provide hospitals and health systems with the highest quality teams of expert Physician Advisors ever assembled in the healthcare market. Our teams are dedicated to ensuring medical necessity compliance and revenue integrity, and improving reimbursement while optimizing hospital efficiency and helping to increase quality of care.
The combination of our cutting-edge Physician Advisor team model and technologies, and our best-in-class portfolio of solutions results in a unique offering that no other organization in the healthcare industry today can match.”
I highly recommend this corporation. It is much easier to work with an off-site, neutral group of physicians who do not have any professional or personal ties with the physicians within my hospital.
Jane Arnold
Janet A. | Jun 24, 2009 | Reply
Jane,
Our small rural hospital uses EHR services and it has been very valuable. It is much easier to argue a denial when a team of physicians makes the determination. Supposedly EHR is an outside independent opinion, although they are paid by the reviewing hospital per case. The UR person can have the heat taken off him/her when using EHR. They are the ones making the final decision, and the UR nurse is not having to track down a PA during a busy day.
Janet A.