There is for UM nurses and physician advisors one nagging question: since when did a one size fit all? That’s a subject for clinicians to debate. MCG in particular wants us to accept that following their guidelines leads to better outcomes. Drive practice in a way most advantageous to patient outcomes? That’s a question of evidenced based practice. Can they be useful in keeping us honest? Only if you believe the playing field is level. Yet there is still the issue of what to trust.Ĭan MCG and InterQual serve as reasonable tools for determining initial status? Only if you like leaving money on the table by starting every hospitalization as observation and see no problem with 4 day observation stays. There’s a lack of transparency and attention to detail in the application of MCG by payer medical directors. There are other factors such as plain misuse, such as applying critical care criteria to a medical unit patient. Please ignore the paradox in that statement, but we have to start somewhere. Ok, I’ve said it in much stronger terms in this forum and others and it’s not a theory if payer denial letters and MCG sales people are to be believed. I have theorized that it’s because MCG allows its proprietary content to be modified in ways we providers are not privy. This begs the question of why (nifty features, coming up!). Those of us with hands-on experience in fighting or avoiding denials can attest that MCG is the hands-down favorite of payers. You would expect few differences except for nifty features, but not substantial content differences. Put head-to-head, however, and there’s a problem. Each product had their unique beginnings and purposes. When it comes which product, MCG or InterQual is best, I have friends on both sides, including some involved in product development. So, what role can we expect these national standards to play? (You can read my RAC Monitor piece on the death of national standards). Certain patients hospitalized under observation may have had their due process rights violated by applying MCG and InterQual in admission status decisions. Azar that over-reliance on MCG and InterQual created the basis for granting appeal rights to a class of patients hospitalized under observation. In March a Connecticut US District Court judge ruled in Alexander v.
There’s much to unpack, especially for nurses and physicians new to UM.
#MCG HOSPITAL HOW TO#
Unabashedly, this is a teaser for an upcoming webinar “ How to Outflank Capricious and Arbitrary Medical Necessity Guidelines from Payers” – a deep-dive look to the role and relevance of these two national standards for guiding a hospital’s utilization and denial management efforts.
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