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Reliable, evidence-based clinical content: InterQual Criteria provide appropriateness of care decision support covering medical and behavioral health across all levels of care as well as care planning and complex care management.
26 Jun 2014 Couldn't find any info about InterQual training using that link. I have searched high and low for a class on InterQual but have been unable to find one so far. I did find a 4 hour introduction to Utilization Review: MCG (Milliman Care Guideline) -- Utilization Review Criteria: Inpatient and Surgical Care-Milliman
Nonetheless, documentation of patient acuity, intensity of services required, and the clinical reasoning that justifies an inpatient admission is critical to convince these payers that inpatient care is warranted or to appeal unfavorable decisions. Guidelines like InterQual® and Milliman (now “MCG"), are often recommended and
In addition, there are cases when inpatient screening criteria are met and the payer denies payment because the documentation, in their view, did not support the necessity for inpatient care. Hospital appeal of payment denials is always an option, but requires additional time and expense. Today, admission decisions must
Essentially, medical necessity means an illness must be severe enough, and the required services intense enough, that care can only be given safely and effectively in the The most recognized and frequently used are the InterQual and Milliman criteria, which have been validated by research and decades of clinical use.
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27 Jan 2010 Care guidelines are essential for ensuring the medical necessity of inpatient stays, using resources appropriately, and appealing denials. Although care guidelines products such as Milliman and InterQual are no substitute for a physician's professional opinion, hospitals nationwide use them every day.
17 Nov 2012 s InterQual and the Milliman Care Guidelines—say such systems have helped erode physicians' power to make hospital admission decisions, potentially to the detriment of patients' health and finances. And while the trend has been growing because of the RACs' use of the systems, the maker of one of

help hospitals and insurances companies assess the appropriate level of care for a patient, which then determines the level of reimbursement for that patient. Attempted forays by both InterQual and Milliman to introduce the use of standardized clinical criteria for this purpose in certain other countries, however, appear not to

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March 2018