UM/CM Interqual Fraud

[RobCPhT]

Can someone help me with a "Scenario"?

Let's say that a Utilization Management department of a health plan decides to not run Interqual on a breast reduction request and they deny the service, but in the denial they state they used Interqual guidelines when in fact none were used and when Interqual is later checked the surgery actually does meet and should have been approved.

Now let's say this trend has been going on quite a bit to "save time". I think it's false documentation.

Can anyone provide me with objective information (Interqual policy, regs, etc.) against this practice?

[IngyRN]

I am not quite sure I am understanding. Is this a nurse reviewer for an insurance who you are referring to? Why do you feel there is "false documentation"? Are you privy to their documentation or are you referring to what they are communicating to you?

If the health plan uses Interqual as their criteria-you certainly have grounds for making the appeal that this indeed meets inpt criteria. If this is seen as a "trend" re: false documentation, it needs to be taken up by the reviewer's supervisor. As far as I know, Interqual just provides the criteria-it is the facility or insurance's job to make sure that those agents using Interqual are using it correctly.

Although, a breast reduction is one of those inpt procedures that have an "*" so it can be obs as well ( I am referring to the 2007). Perhaps that is why it was denied?

[RobCPhT]

I apologize for not being more informative. I work for an insurance company that has way too many cases. Here is what is happening: To save time the director over the UM department is advising staff members to not run interqual for requests, but to "just wing it". On the documentation that is sent to the department of insurance and to our providers the denials state that Interqual criteria was used, when in fact is was not.

This directive was hush hush, and I found a few of these when I was reviewing cases for medication compliance. I asked around a few individualss said they didn't like the idea, but did it anyway.

I want to challenge it because its unethical, but I need something to back my case up.