Tips from the RAC Cave: "Interqual vs. Milliman"

Payment Matters Newsletter

July 1, 2009

By: Paul W. Kim* and Mark A. Stanley*

(RAC Man and QIC Boy Wonder)

Except in one State, neither Interqual nor Milliman represents Medicare coverage criteria or policies. CMS knows it, and so do the RACs. Therefore, other than in that one State, the RACs may not utilize either Interqual or Milliman to deny claims. However, when appealing RAC audit findings, it remains useful to demonstrate that the service meets either Interqual or Milliman as further support that the service complies with the Medicare coverage rules. To date, only the Medicare contractor for Florida has adopted Interqual as its local Medicare criteria. Hence, the RAC for Florida has indicated its intent to apply Interqual in its review of claims.

In our next issue, same RAC time, same RAC channel: "Pre-RAC Audits vs. RAC Preparation."


* Paul W. Kim and Mark A. Stanley are former members of Ober|Kaler's Health Law Group.