Well, I gave you all a break from my criticism of insurance company policies and ploys last week, and I had planned to go for a record second consecutive week, but then, things changed.
As you may recall, a few weeks ago I talked about how payers were denying inpatient admission because IV fluid rates did not meet commercial criteria, despite us being in the midst of a nationwide IV fluid shortage – and physicians doing their best to limit usage.
I also posted a discussion on the topic to LinkedIn, and of course, received many supportive comments, confirming that these denials were occurring.
Well, last week, a post showed up in my feed from a physician reiterating the seriousness of the shortage and discussing how physician documentation of the rationale for limiting IV fluids can support the clinical decision-making process when the case is sent for secondary review after failing criteria.
The physician went on to say that “the InterQual® criteria are developed utilizing the best available evidence to support the primary review for medical necessity determinations. The criteria are not intended to be the sole determination for non-determination decisions. Outliers – cases where criteria are not met – should always be referred to secondary review. The secondary reviewer should apply clinical judgment and knowledge to the case in order to render a decision specific to the individual clinical scenario.
Factors such as age, comorbid conditions, social drivers of health, and other patient-specific factors should be considered. Significant supply chain disruptions – such as the recent IV fluid shortage – serve as valuable examples of extenuating circumstances that are likely to recur in the future and warrant thorough discussion.”
What a great summary!
But here is the amazing thing: that post was authored by the medical director of InterQual®. The director of InterQual®, telling us that cases that fail criteria should always be sent for secondary review.
But… who owns InterQual®? Change Healthcare, which is owned by Optum. And Optum is owned by UnitedHealth Group, which owns UnitedHealthcare, one of the payers that are denying admissions for not having the criteria-required rate of IV fluids. That’s right: the very same UnitedHealth Group.
So, I asked him how UnitedHealth Group can allow UnitedHealthcare to misuse their own product, InterQual®?
The answer, according to this medical director, is that “Optum and UnitedHealthcare (UHC) are two entirely separate entities.” He added that he does not know the specific practices of UHC nor any other health plan; however, UHC is like any other health plan that uses their rigorously developed evidence-based screening criteria for primary reviews.
I just cannot accept this explanation.
Now, if this was any other payer, then sure, they are free to purchase any commercial criteria set and ignore the basic guidelines on the correct use of the criteria in order to increase their corporate profits, but when the payer and criteria publisher have the same owner, there is no excuse.
Now, what to do about it?
Well, if they are denying Medicare Advantage (MA) inpatient admissions that meet the provisions of the Two-Midnight Rule because criteria were not met, then they are violating federal regulations and a complaint to the Centers for Medicare & Medicaid Services (CMS) is warranted.
If it is not an MA patient, collect the data and leave it to your finance and contracting teams to address this with the payer.
These opinions are those of Dr. Hirsch and not R1 or MedLearn Media.
EDITOR’S NOTE:
The opinions expressed in this article are solely those of the author and do not necessarily represent the views or opinions of MedLearn Media. We provide a platform for diverse perspectives, but the content and opinions expressed herein are the author’s own. MedLearn Media does not endorse or guarantee the accuracy of the information presented. Readers are encouraged to critically evaluate the content and conduct their own research. Any actions taken based on this article are at the reader’s own discretion.
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