Krystal Revai MD, MP discusses peer to peer pointers for assignment of appropriate levels of care for hospitalized patients
She defines in patient and observation levels of care, as well as how the guidelines for the use of InterQual and Milliman are different. She shares what clinicians can do to ensure that their patients are admitted under the appropriate level of care and what can be done if the insurance company disagrees with a determination that a member should be inpatient and downgrades them to observation.
Peer to Peer Pointers for Successful Prior Authorizations
Featuring:
Krystal Revai, MD, MPH
Krystal Revai, MD, MPH is the Health Alliance Associate Chief Medical Officer.
Transcription:
Melanie: Welcome to Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole. Today, we're offering peer-to-peer pointers for assignment of appropriate levels of care for hospitalized patients. Joining me is Dr. Krystal Revai. She's the Associate Chief Medical Officer at Health Alliance, a part of the Carle Health System.
Dr. Revai, thank you so much for being with us. This is a really great topic that confuses both patients and providers, and it may be news to some of our listeners that a person can be admitted to the hospital under two different levels of care, inpatient and observation. Can you explain the difference between these two levels of care? And then also describe the difference between inpatient and observation levels of care for the hospitalized patient.
Dr. Krystal Revai: Yeah. I would love to. So the first is observation level of care, and that is a designation that really is for people who may encounter the health system and need some additional tests or observation, but are not quite serious enough to warrant, you know, an extended hospital stay. Perhaps they just need some intravenous fluids, perhaps they need test that can only be done in the hospital. We would admit them under the observation level of care, which is really an extension of an outpatient level of care.
And then we have inpatient level of care, which is really for our more sicker patients. These are patients who perhaps need an extended recovery from surgery. They need more tests. They may have, you know, a serious infection or sepsis. And then certainly if they are, you know, intensive care or requiring extensive monitoring, they would need inpatient level of care.
Melanie: Well, thank you for that. So then can you tell us a little bit about InterQual and Milliman? How are those guidelines different? Tell us what they are. Explain a little bit about that for us.
Dr. Krystal Revai: So Milliman which has subsequently changed his name to MCG, but the colloquial term for it is Milliman. We'll just continue to refer to it as Milliman for the purpose of our podcast. Milliman and InterQual are two different essentially companies that take the evidence and look at the intensity of service as well as the severity of illness and, based on the evidence, feel that if a member or a patient meets certain criteria, they do qualify for inpatient level of care versus an observation level of care.
A couple of differences, so MCG, it is designed a little bit differently for the way that people access it, the way that people look at the guidelines. It is very comprehensive. You look based on the disease state and age and it really puts a lot of emphasis on the patient's severity of illness. As opposed to InterQual, now, the nice thing about InterQual, it also has criteria for whether or not a person meets criteria for any level of, you know, hospital level of care, whether it's inpatient or observation. And it also really addresses not just the severity of illness, but also the intensity of services.
And so that's just an added layer for how they determine whether somebody meets criteria for inpatient level of care or observation. We at Health Alliance do use InterQual to make our determinations, whether if somebody meets inpatient or observation level of care. Also, the way that InterQual sends you through a series of steps and questions and to help you sort of discern almost like a decision tree as to whether or not what the patient's level of care is.
Melanie: Well, along those lines then, Dr. Revai, tell us about key documentation inclusions for decision-making.
Dr. Krystal Revai: Well, obviously, you know, fully documenting the patient's presentation, their severity, what the plan is. I think that the key to documentation is really awareness around what the criteria are. And so, you know, for our hospitalists, I do encourage them to, especially for common diseases, like sepsis, respiratory failure, renal failure, get to know what the MCG criteria and InterQual criteria are for inpatient level of care and observation, so that your documentation can be really specific for what the reviewers are looking for.
Melanie: Well then, doctor, what are some of the more important things clinicians can do to ensure that their patients are admitted under the appropriate level of care?
Dr. Krystal Revai: I think what clinicians can do is after they become familiar with the guidelines for the condition that they're admitting the patient for is to clearly document the condition and the signs that MCG or InterQual are looking for that documents the severity of illness so that they do meet for inpatient level of care. And I think that another thing that physicians can do is knowing that a member might meet the criteria for an observation level of care, documenting that and it could also save them the time with further documentation or a peer to peer phone call, "This person clearly meets for observation level of care. I'm going to document it as such and continue to care for my patients."
Melanie: This is a really important topic. And I think one of the key messages I'm hearing from you is to understand and know those criteria and especially for the most common conditions to know what those symptoms and criteria are. So if the insurance company disagrees with a determination that a member should be inpatient or downgrades them to observation, is there anything that can be done?
Dr. Krystal Revai: Absolutely. If a health insurance company does not feel that the documentation shows an in-patient level of care is warranted and they decide that the patient meets for observation level of care, but the physician disagrees, they can request a peer-to-peer phone call with a medical director from the health plan so that they can explain how the member meets in-patient level of care criteria. But before that phone call happens, they definitely want to familiarize themselves with the criteria.
And just because perhaps their documentation could have been clearer, just because it wasn't in the original documentation, most health insurance companies will accept an amendment to the medical record.
Melanie: I'm glad you mentioned that because that was going to be my next question, is can they amend the original record to better adjust so that those sufficient symptoms and criteria are met?
Dr. Krystal Revai: Yes, absolutely. Amendments to the medical record are accepted.
Melanie: So why don't you wrap it up for us, Dr. Revai, as the Associate Chief Medical Officer at health Alliance, to what you feel you want peers to know about really this topic of successful prior authorizations, because it can be confusing to both patients and their families, but certainly to healthcare providers as well.
Dr. Krystal Revai: I think what I want healthcare providers to know is that health plans want their members admitted under the appropriate level of care because it helps us know further down the road what assistance the member may need. So if someone is continually being admitted under an observation level of care, it may mean that they need more followup with their PCP or perhaps they could benefit from a health coach or care coordination, so they aren't bouncing in and out of the hospital for these short hospitalization stays. On the opposite side, if someone meets an inpatient level of care, perhaps they have heart failure or they have COPD, so they could also benefit from other supports within the health plan. So it's important to us for members to be admitted to the appropriate level of care, but we need that documentation in order to assure that they are admitted under the appropriate level.
Melanie: I think. it would save healthcare costs all around if we do have successful prior authorizations and those criteria are met and that we're all on the same page. I really appreciate you joining us today. This was a really important topic. And thank you so much, Dr. Revai, for joining us today and helping to clear up some of the confusion when it comes to assignment of appropriate levels of care for hospitalized patients.
For more information and to get connected with one of our providers, please visit carle.org or for a listing of Carle providers and to view Carle-sponsored educational activities, please visit our website at carleconnect.com. That concludes this episode of Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole.
Melanie: Welcome to Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole. Today, we're offering peer-to-peer pointers for assignment of appropriate levels of care for hospitalized patients. Joining me is Dr. Krystal Revai. She's the Associate Chief Medical Officer at Health Alliance, a part of the Carle Health System.
Dr. Revai, thank you so much for being with us. This is a really great topic that confuses both patients and providers, and it may be news to some of our listeners that a person can be admitted to the hospital under two different levels of care, inpatient and observation. Can you explain the difference between these two levels of care? And then also describe the difference between inpatient and observation levels of care for the hospitalized patient.
Dr. Krystal Revai: Yeah. I would love to. So the first is observation level of care, and that is a designation that really is for people who may encounter the health system and need some additional tests or observation, but are not quite serious enough to warrant, you know, an extended hospital stay. Perhaps they just need some intravenous fluids, perhaps they need test that can only be done in the hospital. We would admit them under the observation level of care, which is really an extension of an outpatient level of care.
And then we have inpatient level of care, which is really for our more sicker patients. These are patients who perhaps need an extended recovery from surgery. They need more tests. They may have, you know, a serious infection or sepsis. And then certainly if they are, you know, intensive care or requiring extensive monitoring, they would need inpatient level of care.
Melanie: Well, thank you for that. So then can you tell us a little bit about InterQual and Milliman? How are those guidelines different? Tell us what they are. Explain a little bit about that for us.
Dr. Krystal Revai: So Milliman which has subsequently changed his name to MCG, but the colloquial term for it is Milliman. We'll just continue to refer to it as Milliman for the purpose of our podcast. Milliman and InterQual are two different essentially companies that take the evidence and look at the intensity of service as well as the severity of illness and, based on the evidence, feel that if a member or a patient meets certain criteria, they do qualify for inpatient level of care versus an observation level of care.
A couple of differences, so MCG, it is designed a little bit differently for the way that people access it, the way that people look at the guidelines. It is very comprehensive. You look based on the disease state and age and it really puts a lot of emphasis on the patient's severity of illness. As opposed to InterQual, now, the nice thing about InterQual, it also has criteria for whether or not a person meets criteria for any level of, you know, hospital level of care, whether it's inpatient or observation. And it also really addresses not just the severity of illness, but also the intensity of services.
And so that's just an added layer for how they determine whether somebody meets criteria for inpatient level of care or observation. We at Health Alliance do use InterQual to make our determinations, whether if somebody meets inpatient or observation level of care. Also, the way that InterQual sends you through a series of steps and questions and to help you sort of discern almost like a decision tree as to whether or not what the patient's level of care is.
Melanie: Well, along those lines then, Dr. Revai, tell us about key documentation inclusions for decision-making.
Dr. Krystal Revai: Well, obviously, you know, fully documenting the patient's presentation, their severity, what the plan is. I think that the key to documentation is really awareness around what the criteria are. And so, you know, for our hospitalists, I do encourage them to, especially for common diseases, like sepsis, respiratory failure, renal failure, get to know what the MCG criteria and InterQual criteria are for inpatient level of care and observation, so that your documentation can be really specific for what the reviewers are looking for.
Melanie: Well then, doctor, what are some of the more important things clinicians can do to ensure that their patients are admitted under the appropriate level of care?
Dr. Krystal Revai: I think what clinicians can do is after they become familiar with the guidelines for the condition that they're admitting the patient for is to clearly document the condition and the signs that MCG or InterQual are looking for that documents the severity of illness so that they do meet for inpatient level of care. And I think that another thing that physicians can do is knowing that a member might meet the criteria for an observation level of care, documenting that and it could also save them the time with further documentation or a peer to peer phone call, "This person clearly meets for observation level of care. I'm going to document it as such and continue to care for my patients."
Melanie: This is a really important topic. And I think one of the key messages I'm hearing from you is to understand and know those criteria and especially for the most common conditions to know what those symptoms and criteria are. So if the insurance company disagrees with a determination that a member should be inpatient or downgrades them to observation, is there anything that can be done?
Dr. Krystal Revai: Absolutely. If a health insurance company does not feel that the documentation shows an in-patient level of care is warranted and they decide that the patient meets for observation level of care, but the physician disagrees, they can request a peer-to-peer phone call with a medical director from the health plan so that they can explain how the member meets in-patient level of care criteria. But before that phone call happens, they definitely want to familiarize themselves with the criteria.
And just because perhaps their documentation could have been clearer, just because it wasn't in the original documentation, most health insurance companies will accept an amendment to the medical record.
Melanie: I'm glad you mentioned that because that was going to be my next question, is can they amend the original record to better adjust so that those sufficient symptoms and criteria are met?
Dr. Krystal Revai: Yes, absolutely. Amendments to the medical record are accepted.
Melanie: So why don't you wrap it up for us, Dr. Revai, as the Associate Chief Medical Officer at health Alliance, to what you feel you want peers to know about really this topic of successful prior authorizations, because it can be confusing to both patients and their families, but certainly to healthcare providers as well.
Dr. Krystal Revai: I think what I want healthcare providers to know is that health plans want their members admitted under the appropriate level of care because it helps us know further down the road what assistance the member may need. So if someone is continually being admitted under an observation level of care, it may mean that they need more followup with their PCP or perhaps they could benefit from a health coach or care coordination, so they aren't bouncing in and out of the hospital for these short hospitalization stays. On the opposite side, if someone meets an inpatient level of care, perhaps they have heart failure or they have COPD, so they could also benefit from other supports within the health plan. So it's important to us for members to be admitted to the appropriate level of care, but we need that documentation in order to assure that they are admitted under the appropriate level.
Melanie: I think. it would save healthcare costs all around if we do have successful prior authorizations and those criteria are met and that we're all on the same page. I really appreciate you joining us today. This was a really important topic. And thank you so much, Dr. Revai, for joining us today and helping to clear up some of the confusion when it comes to assignment of appropriate levels of care for hospitalized patients.
For more information and to get connected with one of our providers, please visit carle.org or for a listing of Carle providers and to view Carle-sponsored educational activities, please visit our website at carleconnect.com. That concludes this episode of Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole.