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RAC-Approved Screening Criteria: Myth or Reality?

Andrea Kraynak, for HealthLeaders Media, May 28, 2009

Will using InterQual, Milliman, MCAP or other screening criteria help keep RACs off your back?

Perhaps, but you should be aware that these decision-support products are merely screening criteria—and over reliance on them without adequate physician consultation could spell trouble for hospitals financially, says Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance for HCPro, Inc. "They screen for the most likely inpatient and outpatient admissions, but cannot take into account every medical circumstance."

"For example, there are a percentage of patients, who will fail inpatient criteria due to factors not considered in the InterQual criteria that upon physician's review will nevertheless be appropriate for inpatient admission," she adds.

For this reason, each permanent RAC is required to have a medical director who will help develop evidence for individual claim determinations and act as a resource for all reviewers making such individual claim determinations. Additionally, the provider has the opportunity to request that the medical director participate in discussions regarding individual claim denials.

This is an important change from the RAC demonstration program, which didn't require RACs to have a medical director on staff. "The addition of a medical director means that there will be a physician available to review cases that do not meet screening criteria, but still may be appropriate for inpatient admission. Previously these cases were just denied without further review and the hospital had to do costly appeals to demonstrate the medical necessity of the cases," says Hoy.  

So which screening criteria should hospitals use? CMS doesn't require hospitals to use a particular screening tool, such as InterQual. And use of an older version or a different set of criteria than the set being used by the reviewing agency is not inherently a problem. However, because outside entities, such as RACs, Medicare Administrative Contractors, and Quality Improvement Organizations, will be reviewing cases, many hospitals choose to use the same version used by their contractors, says Hoy.

Typically, RACs, MACs, and most hospitals use the screening criteria version that would match the year applicable to the case. Outdated versions may not reflect advances in care and may cause inappropriate screening decisions.

For example, current screening criteria may indicate that based on the severity of their signs, symptoms, other factors a patient should be an outpatient for a particular procedure. However, there may have been recent advances in how the procedure is performed and criteria from prior years may reflect the same signs and symptoms as indicating inpatient admission for the procedure. Failure to use current year criteria may cause an inpatient admission that was not medically necessary because of advances in the performance of the procedure, explains Hoy.

Best practice to prepare for RACs is to know the screening criteria your RAC will be using and ensure your staff are trained in its use. Additionally, a good utilization review process, with the involvement of a medical director to review those borderline cases, will ensure appropriate placement for all cases, including cases that don't easily fit the criteria you are using, says Hoy.

Finally, don't forget that if you suspect only screening criteria were applied to a case and believe there was a good reason for the inpatient admission, providers should avail themselves of the RAC medical director as allowed under the RAC program guidelines, she says.


Andrea Kraynak, CPC, is senior managing editor of Medical Records Briefing and HIM Connection. She may be reached at akraynak@hcpro.com.


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