MCG vs. IQ and Does it Even Matter?

Marina Shpilko, DO
ACPA Member

UnitedHealthcare, the country’s largest healthcare insurance provider, has transitioned their guidelines for determining level of care for hospitals from MCG Care Guidelines (MCG) to InterQual® clinical criteria. This change took place on May 1st, 2021. The shift included nearly all their commercial, Medicare Advantage and Medicaid benefit plans. This was a big change for hospitals with a large population of United Healthcare patients. 
There was some concern that InterQual’s criteria may be stricter than MCG’s, possibly resulting in an increase in the number of denials and poorer outcomes for peer-to-peer overturns. (Revenue Cycle Advisor “Q&A: New UnitedHealthcare Guidelines, Analysis” March 3, 2021. https://www.healthleadersmedia.com/revenue-cycle/qa-new-unitedhealthcare-guidelines)  
What are the differences between InterQual® and MCG criteria? 
There are differences in how they are laid out and how they are viewed. Further, as summarized by a revenue recovery organization, “the criteria set out in MCG is less precise, leaving room for interpretation. On the other hand, InterQual ® is very specific and detailed in setting criteria for both severity of illness (citing precise vital sign abnormalities, lab values, test results, etc.) and intensity of service (specific treatments/treatment plan that must be done) to meet inpatient level of care.”(InterQual® vs. Milliman Care Guidelines. April 29, 2021. https://www.myadvicare.com/post/interqual-vs-milliman-care-guidelines). 
At University Hospitals in Northeast Ohio, we sought to answer how United HealthCare’s change to InterQual® has impacted our institution. We looked at our data 4 months pre-, and 4 months post-adoption of InterQual® by United Healthcare, in terms of overall denial rates, total peer-to-peers performed, and rate of peer-to-peer success. In addition to examining UHC as an organization, we broke it up by each individual UHC participant, namely commercial, Medicaid, and Medicare Advantage, as presented sequentially in this table. 
UH data: 4 months pre and post UHC adoption of InterQual®:
Interpretation of our Results: 
Our data demonstrates that the overall denial rates and medical necessity denial rates for UHC following their implementation of InterQual® was not statistically significant. Further, our peer-to-peer success was somewhat improved post adoption of InterQual® by UHC.  
 
Discussion: 
The peer-to-peer success was minimally impacted by the adaptation of InterQual®, and positively at that. Part of the reason is that when Physician Advisors are doing a peer-to-peer with medical directors, the official criteria is only a portion of the picture we’re presenting. These are guidelines, not a substitute for physicians’ medical judgment.  
We will continue to keep tracking and monitoring the trends for overall denials, number of peer-to-peers completed, and our overturn success rates to assess if this course continues. The results obtained are encouraging thus far.  
Dr. Marina Shpilko is a Physician Advisor for Utilization Management for University Hospitals in Cleveland, OH.