How are the Care Guidelines used in the medical management process?
Accrediting organizations, such as NCQA, URAC and The Joint Commission, provide oversight of the care delivery processes of health plans and managed care organizations, as well as other healthcare claims payors in the United States. One of the requirements of the accrediting organizations is the use of guidelines in making medical management decisions. The intent is to assure informed medical decision-making, thereby maintaining a high quality of healthcare. The Care Guidelines are among the most widely used tools of this type.
Denial of payment procedures are contractual issues between payors and providers. The way in which payors make decisions regarding the necessity of care or the level of care is routinely evaluated by the accrediting organizations, and there are defined processes that govern how denial notices should be given.
When the Care Guidelines are cited to the provider in the context of a denial notice, that notice must contain reasons for denial, including an easily understood summary of the applicable utilization management decision criteria from the guideline used. It must also include how the guideline cited is applied to the specific patient’s condition. When a payor adopts this approach, both the provider and the patient are able to understand fully the rationale for the healthcare organization’s decision.
Our licensing agreements require that all coverage decision communications that reproduce or cite any part of the Care Guidelines must contain the following statement: “Milliman Care Guidelines are not intended to be used without the judgment of a qualified healthcare professional, taking into account the individual circumstances of each patient’s case.”
Use of the Care Guidelines as the sole basis for denying authorization for treatment, without proper consideration of the unique characteristics of each patient, or as the sole basis for denying payment for treatment received, represents inappropriate use of the Care Guidelines.