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Federal Guidelines or Milliman Care Guidelines Time for Industry Attention!

Written by: Mediware on Wednesday, November 23, 2011 Posted in: Inpatient Rehab

I received a heads up a little over a month ago that Milliman Care Guidelines had been adopted by CMS to determine appropriate level of care.   I scoffed at the concept because federal guidelines that you and I get to review as proposed rule before they become final would certainly not be overridden with private company standards without little or no warning.  Yet, sure enough,  the  Milliman Company website  posted this newsworthy announcement back in 2010:

(SEATTLE) November 11, 2010 — Milliman Care Guidelines will provide its evidence-based clinical guidelines to Centers for Medicare & Medicaid Services (CMS) healthcare review contractors through a license with Buccaneer Computer Systems and Services, Inc.”

Milliman website company description: “Parent company Milliman is among the world’s largest independent actuarial and consulting firms. Founded in Seattle in 1947 as Milliman & Robertson, the firm has more than 50 offices worldwide, and employs more than 2,400 people in healthcare, employee benefits, property and casualty insurance, life insurance and financial services consulting practices.”

Its  history and strength is actuarial driven with guidelines that provide LOS targets, utilization models, guidance for extended stay and  continued stay discharge criteria.  They note these are driven through best practice and evidence-based management articles.  However, last I checked, beneficiary reasonable and necessary decisions were legally based on Medicare manual regulations.    If you feel we have been doing a great job in post acute care to provide the needed published research that helps to support specific criteria to determine IRF versus SNF specific care and continued stay – you can stop reading and let these predictive guidelines be your marker for decision.

If you are still reading (and I hope you are), you agree there is limited best practice publications and only recently specific rules to begin tracking quality outcomes.  Take notice that per the Milliman announcement, CMS  ”Contractors will have access to Milliman Care Guidelines products spanning the continuum of care, including Ambulatory Care, Inpatient and Surgical Care, General Recovery Guidelines, Recovery Facility Care, Home Care and Behavioral Health Guidelines.  They will access the guidelines using CareWebQI® interactive software, enabling reviewers to track variances and clearly document decisions during concurrent and retrospective reviews.”   And I question, do the unique skills and interventions of an inpatient rehabilitation facility fall under “General Recovery” or “Recovery Facility”?

I am not sure what due diligence was done to align the Code of Federal Regulations and  CMS Manual mandates against each and every Milliman guideline.  So it begs to question that when Medicare administrative contractors and recovery audit contractors have access to these products, are the clinical standards close enough to published federal standards to approve or deny

Stay ahead of the changes CMS is bringing to your IRF.

access and payment?  If Milliman guidelines can be used to judge  appropriateness of care and continued access with CMS approval,  everyone with Medicare provider status needs to completely understand how they will be used.  A whole host of insurance companies other than Medicare reference Milliman, therefore, to advocate for patient access and continued care it seems facilities need to know information requirements for documentation.  If you don’t agree with the standards as they relate to an IRF level of care, what can be done to provide the evidence to help update the standards?


I think we would all agree that practices must be adopted with specific expectations so that variances are appropriately managed.  Staff and processes must be supported to fulfill expectation criteria.  Those of us long in the field have had some dispute with actuarial guidelines used to inappropriately limit access to care.  The clinical picture and progress of documented care and response to care is hugely important.  The patients documented functional and clinical care and training to enable increased independence is crucial.

What can you do to be sure the patients you treat show continued response to the care provided?  Does your documentation provide information that can be used to concurrently and retrospectively stand toward Milliman specific measurements?  Can you be sure that resources provided can stand up to payment scrutiny?  If these standards are not consistent with Medicare manual guidelines, is your staff ready to recognize the differences and to dispute where appropriate?   Another level of pay for performance has been unveiled.  Were you ready?  Did you recognize that it already occurred?

Outcomes are important – swift changes are occurring!  Evidence-based clinical standards are highly dependent on evidenced-based management.  We must know our expectations and clearly be accountable toward them.   First and foremost – you also must know the standards used to guide decisions.

Finally, a search for Milliman Guidelines at the CMS website revealed no matches.  Generally I receive a Medicare Learning Network (MLN) update for significant beneficiary access and payment criteria.  Don’t you?


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