INTERQUAL

If you are not affiliated with a hospital utilization review office and don’t work for a health insurance company, chances are you have never heard of Interqual. You lucky devil. It is one of the programs used to determine if someones health status and course of treatment warrant an inpatient admission. When it behooves an insurance company, they will deny an inpatient admission as the interqual criteria were not met. Then, talking out of the other side of their mouths, they insurance company many deny someone who met the interqual criteria because, after all, they are just “guidelines”. I am not a huge fan of interqual as it takes certain factors out of the equation, reducing hospital admissions to black and white. As a nurse who has been in healthcare 25+ years I know there are several shades of gray. However there is no one to hold these insurance companies accountable, allowing them to call the shots when it comes to our healthcare. And have you ever noticed that when something is denied and you try to talk with your insurance company the process is so lengthy and tedious you want to just give up? Yeah, insurance companies bank on that, literally.

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