What role do screening tools such as Milliman Care Guidelines (MCG) or InterQual® admission criteria play in writing appeals?
I’m often asked this question when I’m teaching appeal writing in hospitals. Hospitals are tasked by regulations to follow a utilization review program with established procedures for the review of the medical necessity of admissions, the appropriateness of the setting, the medical necessity of extended stays, and the medical necessity of professional services.
There are commercially available screening tools to assist care providers in determining appropriate medical necessity for admission, appropriate level of care and extended stays. If a hospital uses a commercially available tool as an established part of its utilization review program, then by all means, include that information in the appeal. It demonstrates that there is a thoughtful process in place to help the admitting clinician determine the appropriate care setting. Interpret “thoughtful” and “help” to mean the admitting clinician is incorporating some standards of care in his/her decision-making regarding proper placement of the patient, not that the admitting clinician is basing his/her admission decision solely on the outcome of a screening tool.