Medical Necessity Reviews: We will "huff and puff and try to blow your house down!"

The dreaded "it" is out there now for most of the country: the "big bad wolf" issue of medical necessity, already approved in Regions B and D and expanded to Region C on Aug. 27. Region C, Connolly, joined the "wolf pack" and posted the same approved 29 MS-DRGs, adding medical necessity items to its CMS-approved issues.

To see how Connolly describes the issues and the way they will be reviewed, take a look below, and notice the new MS-DRG, 313:

Region C: Connolly

Please note the clarity in the description regarding the focus for these 29 issues, inclusive of DRG validation: the "wolves" are eager, it might seem, to "blow our house down!"

"Medical Necessity" Screening Criteria

Last fall, and again earlier this year, RACmonitor hosted webinars on the use of the nation's two most widely implemented tools (McKesson's InterQual® and Milliman CareGuidelines^TM) for helping provide guidance to providers on medical necessity of services, touching on matters including documented patient conditions, symptoms and possible location for the service provision (inpatient hospital, outpatient). The sessions generated a great deal of interest, dialogue and more than a little "heat." Questions have continued to come in during recent months regarding which criteria the RACs will use and how providers should respond to denials for medical necessity when or if they should occur. A recent question (Aug. 16) is posted below, illustrating a theme echoed by many questions we have received;

Question: "We continue to see statements that the RACs do not necessarily have to strictly use InterQual or Miliman when their nurses review for medical necessity.  So, how are these decisions made if not by using objective criteria?"

Rephrased another way, the expressed concern appears to be "we use  criteria x, so what do they use? Shouldn't they use the same, and if not, how can their decisions be valid?" Both questions have been answered by CMS in the final RAC statement of work and in two very recent publications released this year. Let's get to it then...

The 2007 final RAC statement of work clearly lays out what is expected from the RAC and the provider regarding reviews of previously submitted claims (Oct. 1, 2007 forward) and supportive claim documents, so let's review the language from key sections: