By Tom Tinsman, MD

The physician advisor review of medical necessity of inpatient stays, either when the question concerns the necessity of an initial inpatient admission, or subsequent days of the stay, is one of the more important functions of review. It is where the extensive clinical experience and training of our physician advisors can really shine through.

Medical necessity of admission
When the question is the medical necessity of admission, the most important aspect of the review is for the reviewing physician to place himself or herself in the position of the attending physician. Ask the question, “Would I attempt to manage this patient without an acute care admission?” Then, the reviewing physician should build a logical, step-by-step explanation in the rationale, explaining the answer to that question. When completed, reread the rationale to assure that it provides the intended answer in an understandable fashion. Medical shorthand, abbreviations and other “shortcuts” that are subject to misunderstanding or misinterpretation should be avoided whenever possible.

Continued length of stay
The same thought and writing process should occur when the question is continued length of stay of an admission. The question that needs to be asked is, “Would I discharge this patient on the day proposed by the initial reviewer?” Write a logical rationale that clearly conveys the answer to that question.

Initial level review
When performing initial level review, it is important that physician advisors not rely too heavily on “nationally recognized criteria,” which are often referenced by the nurse reviewer. The “criteria” being referenced is InterQual, a standardized review system used by our clinical review nurses to determine when it is obvious that a patient requires an acute level of care. This is a very complex system and requires extensive training to create a proper result. Even when optimally used, InterQual is simply a screening tool. InterQual does a decent job of telling you when an otherwise healthy patient with a single acute problem is ready for discharge. It is much less useful for determining when a patient with multiple, interacting comorbidities and/or multiple, interacting acute medical issues is ready for discharge. The same deficiency exists in other standardized, “nationally recognized criteria,” which is why we ask our physician reviewers not to use or even reference such criteria in their decisions. In such a case, reviewers should apply their clinical experience and knowledge of those complex medical interactions to develop a much fairer determination of when a medically complex patient is stable enough for outpatient management.

Reconsideration review
When performing reconsideration review, please remember that Arkansas has a small medical community and we cannot specialty-match initial reviews for all cases. Thus, the only guarantee is, if the case upon which you are performing reconsideration review was initially denied, that denial was issued by a physician with an active, unrestricted Arkansas physician license. However, that physician may have nowhere near your level of expertise in the case under review. In addition, for the Medicaid Utilization Management Program (MUMP) type of review, the initial reviewing physician did not have the actual medical record available when the decision was made for initial denial of payment for acute care services. As a reconsideration physician, you are under no obligation to support the initial physician’s decision.

It is also particularly important for reconsideration review, if the patient’s attending physician wrote the reconsideration request, to give great weight to the attending physician’s concerns. There is a statutory presumption that the attending physician is best suited to determine a patient’s course of treatment and stability for discharge or transfer to a setting less intense than acute care. Each point that the attending physician raises in support of the decision to continue acute care must be specifically rebutted with facts from the medical record and/or established medical literature, if the initial denial is to be upheld.

It is important to understand that, while a reconsideration physician may never deny more days than were originally denied on the initial review, some of the originally denied days may be approved with other days remaining denied. In a case where the denial of some of the days is reversed, but some remain denied, extra care should be taken to explain the split in the reconsideration rationale.  The days that are to remain denied should be specifically mentioned.

As with all articles, your comments, feedback or correction are greatly appreciated.

Dr. Tinsman is an associate medical director at AFMC and team lead in AFMC’s review department.