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.

Screening tools are based on standards of care in the medical community and updated on a regular basis. So, it makes sense to use those tools to assist in decision making for the proper care setting. However, most payers do not recognize commercially available screening tools as the final word in supporting or refuting the need for hospital care, which is a good thing because there is always room for differing interpretations, differing scenarios with patient presentation (extenuating circumstances, comorbid conditions), and to a lesser degree, differing opinions on the standards of care.

If managed care payers make it known that they use a commercially available screening tool to determine an appropriate level of care for payment, and providers accept that as the final word, then there is no door left open for appeal. A provider who accepts the outcome of a screening tool utilized by a payer as the sole reason to deny payment is boxing themselves into a very narrow payment structure without allowing an opportunity to introduce other arguments regarding standards of medical care into an appeal.

Do you incorporate screening criteria in your appeals?