Thinking about working in utilization management? Or have you already landed your dream remote nursing job in prior authorizations and aren’t sure what to expect?
Whether you’re dipping your toes into the remote world for the first time, or you want to pivot your current remote career, we’ve got you covered. Let’s do a deep dive into two essentials for remote nursing jobs: MCG and InterQual.
What Are MCG and InterQual?
Back in the late 70s and 80s, both InterQual and MCG were created to provide some type of guideline to make sure hospital admissions were appropriate and necessary. Today, these accredited guidelines are a staple for insurance companies and third-party reviewers to approve and deny insurance claims. They apply to inpatient admissions, DMEs, labs, procedures, and virtually all health services.
MCG, formerly called “Milliman Care Guidelines” and InterQual both have annual edition updates to keep up with modern evidence-based practice. MCG criteria are typically regarded as more simplistic and user-friendly, while InterQual is a bit more thorough.
Treating providers have scrutinized both guidelines carefully. The sensitive nature of insurance claims can easily cause conflict between providers and insurance companies. But your remote nursing role doesn’t ask you to join the fray. Your job is simply to measure the criteria against clinical documentation. You approve the service based on the criteria, or you elevate the case to a licensed provider to determine if it should be denied.
Both MCG and InterQual require employers to enter a licensing agreement to have access to their proprietary criteria. There are several types of licensing agreements, but what it comes down to on the user end is:
- Interactive criteria
- Non-interactive criteria
The non-interactive versions are web or pdf versions of the guidelines. This takes a bit more concentration to follow and keep track of when the patient no longer meets the guideline.
The interactive version allows you to check the boxes where the patient meets and doesn’t meet the criteria, and then will tell you if the patient ultimately would qualify for an approval.
What Skills Do Remote Nurses Need to Use MCG and InterQual?
Both MCG and InterQual require clinical skills to utilize. You have likely used many of these skills at some point in your nursing career.
Data abstraction is the ability to look through clinical documentation to find key pieces of information. Experience in various charting systems, like Epic, Cerner, or Meditech can be helpful.
Information you may need to find when using MCG or InterQual could range from previous treatments to lab values to current symptoms. Finding that data in the documentation is pivotal to ultimately making an insurance authorization.
Logic and Reasoning
All forms of nursing require critical thinking skills, and utilization review and management are no different. Sometimes the criteria from MCG or InterQual aren’t straightforward.
If the patient is requesting an injection for back pain in the facet joints, the criteria may ask, “Does the patient have signs or symptoms of non-facet etiology?” As a remote nurse, you would have to know (or look up) what symptoms may be present in back pain with a non-facet etiology. Then, you would need to scan the medical record for these symptoms.
Fortunately, these criteria also have their own footnotes, resources, and studies to accompany them. Most utilization review and prior authorization nurses end up working in teams, so you’ll also have your co-workers as a resource.
MCG and InterQual require that you have a basic knowledge of medical terminology. As nurses, many of us feel comfortable in our specific specialty areas. However, utilization management nurses can end up doing reviews for any type of request. This means your L&D knowledge might be helpful for a hyperemesis medication authorization, but may feel less useful in an orthopedic review. You may need to pull that knowledge out from the dusty corners of your brain and get familiar with them again.
Medical Billing and Coding
Utilization review and management is not billing and coding, but it does help to have some basic knowledge of ICD-10 codes, CPT codes, and HCPCS codes. You don’t have to memorize these, but you will learn how diagnosis codes match up to CPT codes. Most importantly, you’ll need to be able to catch a code that looks out of place.
Let’s Dive Into Some Criteria
Let’s take a look at two scenarios that demonstrate what it’s like to use MCG and InterQual.
Non-Clinical Scenario: Grocery Shopping
First, let’s start with a non-clinical example. Let’s pretend that you’re going grocery shopping with a coupon in hand. In order to get 100% off your groceries, you have to meet certain criteria.
You are a 25-year-old female grocery shopper. You are doing your weekly grocery shopping. Your first stop was in the dairy section, since they didn’t have any of your favorite oat milk, you picked up a carton of skim milk instead. You fill your cart with one box of cereal, a package of chips, and a box of pancake mix. In the produce section, you grab some asparagus and two red bell peppers. You also grab a bundle of bananas, a box of strawberries, and two mangoes.
To qualify for 100% off your groceries, you must meet ALL of the following:
o You must be at least 18 years of age
o You must have at least 2 of the following vegetables in your cart:
– Brussel sprouts
– Bell pepper
o You must have more produce (fruit, vegetables, and dairy) than pre-packaged items in your cart
o You must have at least 1 fruit in your cart
o You can only purchase dairy milk if there was no oat milk available or in stock
Yes. You met the criteria to receive 100% off your groceries. You are 25 years old. You had both asparagus and bell peppers in your cart. You have only three pre-packaged items compared to eight items of produce. You have several fruits in your cart. You only purchased dairy milk because no oat milk was available.
Clinical Scenario: Septoplasty
Let’s continue with a medical example:
Your patient’s medical provider has requested a septoplasty.
A 42-year-old male patient has a history of chronic congestion causing difficulty breathing through the nose, which has been ongoing for 5 years. The patient has attempted to take an intranasal antihistamine for 3 weeks, but it did not provide much symptom relief.
The physical exam revealed inferior turbinate swelling and a deviated septum. The patient was diagnosed with sinusitis.
(Note: This is criteria based loosely on InterQual and MCG, but is not copied directly)
To qualify for a septoplasty, the patient must meet ALL of the following:
o The patient has a deviated septum or some type of septal trauma
o The patient has documented symptoms from the obstruction, including ONE or more of the following:
– Difficulty breathing through the nose
– Difficulty with stuffiness or congestion
o The patient has attempted conservative treatment
o The provider has documented there are no other likely causes for obstruction
No. The patient does not qualify for a septoplasty. The provider documented that the patient had inferior turbinate swelling, which could be causing some obstruction. The provider would need to rule this out as a cause of the obstruction.
How to Learn More
Both MCG and InterQual products are proprietary and require licensing, so you won’t find much of their material online. To learn more about how clinicians use these products, try searching on YouTube.
MCG has a certificate program for case managers and utilization reviewer specialists.
Here are the eligibility requirements:
- You are a licensed healthcare professional
- You work for an organization that has paid for MCG licensing (this encompasses many insurance companies and healthcare organizations)
The test costs $150 and requires the completion of course assignments over a 13-week period, and at least an 80% score on the final knowledge test.
Hone Your Craft
Understanding the basics of MCG and InterQual will help you feel confident in tackling the foreign world of remote nursing jobs. From utilization review to case management, the opportunities are endless.
You don’t have to work at the bedside to be a stellar nurse. Who said you would lose your skills in remote nursing? You will gain new ones.
Check out the Nurse Fern blog for more information on remote nursing job roles and certifications.