InterQual v. MCG vs. the Deep Blue Sea 

Unabashedly, this is a teaser for an upcoming webinar offering a deep-dive look into the role and relevance of two national standards for guiding a hospital’s utilization and denial management efforts. There’s much to unpack, especially for nurses and physicians new to utilization management (UM).

In March, a Connecticut U.S. District Court judge ruled in Alexander v. Azar that overreliance on MCG and InterQual created the basis for granting appeal rights to a class of patients hospitalized under observation. Certain patients hospitalized under observation may have had their due process rights violated when MCG and InterQual were applied in admission status decisions. (You can read my RACmonitor piece on the death of national standards). So, what role can we expect these national standards to play?

When it comes to which product, MCG or InterQual, is best, I have friends on both sides, including some involved in product development. Each product had its unique beginnings and purposes. Put head-to-head, however, and there’s a problem. You would expect few differences except for nifty features, but not substantial content differences.

Those of us with hands-on experience in fighting or avoiding denials can attest that MCG is the hands-down favorite of payors. This begs the question of why (nifty features, coming up!). I have theorized that it’s because MCG allows its proprietary content to be modified in ways to which we providers are not privy. Ok, I’ve said it in much stronger terms, in this forum and others, and it’s not a theory, if payor denial letters and MCG salespeople are to be believed. Please ignore the paradox in that statement, but we have to start somewhere.

There are other factors, such as plain misuse, or applying critical care criteria to a medical unit patient. There’s a lack of transparency and attention to detail in the application of MCG by payor medical directors. MCG is not to blame for these. Yet there is still the issue of what to trust.

Can MCG and InterQual serve as reasonable tools for determining initial status? Only if you like leaving money on the table by starting every hospitalization in observation status, and see no problem with four-day observation stays. Can they be useful in keeping us honest? Only if you believe that the playing field is level. Do they drive practice in a way most advantageous to patient outcomes? That’s a question of evidence-based practice. MCG in particular wants us to accept that following their guidelines leads to better outcomes, but that’s a subject for clinicians to debate. There is, for UM nurses and physician advisors, one nagging question, though: since when did one size fit all?

Those steeped in the study of the social determinants of health (SDoH) know that recovery curves and severity of illness directly correlate to social and economic inequities. When a national UM standard sets aggressive recovery timelines, many SDoH-challenged patients are left out in the cold (and providers punished for caring). It’s akin to clinical trials of an antihypertensive only on middle-aged white men in the Ukraine, where genetic diversity is not what you would find in multiethnic populations such as in the U.S. I am not making up this scenario.

What about appeals? Neither MCG nor InterQual ever won me an appeal. As such, MCG and InterQual are weak bases for clinical documentation improvement (CDI) development. Appeals are won on good clinical documentation. Claims paid, the result of good coding based on ICD-10-informed documentation, will always provide the best guidance for CDI initiatives.

UnitedHealthcare (UHC) may have decided to abandon both altogether. Expect others to follow suit. A recent denial of coverage from UHC mentioned neither national standard, instead citing internal medical necessity indicators. It was overcome because the denial was not based on anything factual – that is, anything in the medical record. I received a call today from a HealthNet UM nurse who was unable to access our records remotely. Had she not been thoughtful enough to call (stepping out of protocol), the case would have gone straight to a medical director without any clinical documentation whatsoever.

On the basis of which national standard would such a case be denied? I guarantee that the denial letter would have quoted an MCG guideline. Just saying “we received nothing” would be better, as that recent court case suggests.

Facebook
Twitter
LinkedIn

Marvin D. Mitchell, RN, BSN, MBA

Marvin D. Mitchell, RN, BSN, MBA, is the director of case management and social work at San Gorgonio Memorial Hospital, east of Los Angeles. Building programs from the ground up has been his passion in every venue where case management is practiced. Mitchell is a member of the RACmonitor editorial board and makes frequent appearances on Monitor Mondays.

Related Stories

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

The Cost of Ignoring Risk Adjustment: How HCCs Impact Revenue & Compliance

The Cost of Ignoring Risk Adjustment: How HCCs Impact Revenue & Compliance

Stop revenue leakage and boost hospital performance by mastering risk adjustment and HCCs. This essential webcast with expert Cheryl Ericson, RN, MS, CCDS, CDIP, will reveal how inaccurate patient acuity documentation leads to lost reimbursements through penalties from poor quality scores. Learn the critical differences between HCCs and traditional CCs/MCCs, adapt your CDI workflows, and ensure accurate payments in Medicare Advantage and value-based care models. Perfect for HIM leaders, coders, and CDI professionals.  Don’t miss this chance to protect your hospital’s revenue and reputation!

May 29, 2025
I050825

Mastering ICD-10-CM Coding for Diabetes and it’s Complications: Avoiding Denials & Ensuring Compliance

Struggling with ICD-10-CM coding for diabetes and complications? This expert-led webcast clarifies complex combination codes, documentation gaps, and sequencing rules to reduce denials and ensure compliance. Dr. Angela Comfort will provide actionable strategies to accurately link diabetes to complications, improve provider documentation, and optimize reimbursement—helping coders, CDI specialists, and HIM leaders minimize audit risks and strengthen revenue integrity. Don’t miss this chance to master diabetes coding with real-world case studies, key takeaways, and live Q&A!

May 8, 2025
2025 Coding Clinic Webcast Series

2025 ICD-10-CM/PCS Coding Clinic Update Webcast Series

Uncover critical guidance. HIM coding expert, Kay Piper, RHIA, CDIP, CCS, provides an interactive review on important information in each of the AHA’s 2025 ICD-10-CM/PCS Quarterly Coding Clinics in easy-to-access on-demand webcasts, available shortly after each official publication.

April 14, 2025

Trending News

Featured Webcasts

The Two-Midnight Rule: New Challenges, Proven Strategies

The Two-Midnight Rule: New Challenges, Proven Strategies

RACmonitor is proud to welcome back Dr. Ronald Hirsch, one of his most requested webcasts. In this highly anticipated session, Dr. Hirsch will break down the complex Two Midnight Rule Medicare regulations, translating them into clear, actionable guidance. He’ll walk you through the basics of the rule, offer expert interpretation, and apply the rule to real-world clinical scenarios—so you leave with greater clarity, confidence, and the tools to ensure compliance.

June 19, 2025
Open Door Forum Webcast Series

Open Door Forum Webcast Series

Bring your questions and join the conversation during this open forum series, live every Wednesday at 10 a.m. EST from June 11–July 30. Hosted by Chuck Buck, these fast-paced 30-minute sessions connect you directly with top healthcare experts tackling today’s most urgent compliance and policy issues.

June 11, 2025
Open Door Forum: The Changing Face of Addiction: Coding, Compliance & Care

Open Door Forum: The Changing Face of Addiction: Coding, Compliance & Care

Substance abuse is everywhere. It’s a complicated diagnosis with wide-ranging implications well beyond acute care. The face of addiction continues to change so it’s important to remember not just the addict but the spectrum of extended victims and the other social determinants and legal ramifications. Join John K. Hall, MD, JD, MBA, FCLM, FRCPC, for a critical Q&A on navigating substance abuse in 2025.  Register today and be a part of the conversation!

July 16, 2025

Trending News

Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →

CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24