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Pennsylvania's Healthcare Landscape: Transition to MCG Care Guidelines

In a significant shift aimed at bolstering the quality and consistency of healthcare services, the Pennsylvania Department of Human Services (DHS) will begin utilizing MCG care guidelines to make determinations regarding medical necessity for its Medical Assistance (MA) beneficiaries. This transition marks a pivotal change from the previously employed InterQual Criteria and is set to take effect on July 18, 2025.

A Response to the Need for Consistency in Care Decisions

The Deputy Secretary of the Pennsylvania Office of Medical Assistance Programs, Sally Kozak, emphasized that the adoption of clinical guidelines pertains to a broader commitment from the Department to enhance the consistency of review decisions within the MA program. The MCG care guidelines, developed by MCG Health, part of Hearst Health, focus on providing evidence-based guidance across a variety of healthcare services. Key areas that the new guidelines will address include:

• - Prosthetics, orthotics, and related supplies
• - Durable medical equipment costing over $600 or with rental terms exceeding three months
• - Genetic medicine, including laboratory services
• - Advanced imaging techniques such as CT scans, MRIs, and PET scans
• - Various diagnostic procedures and tests
• - Home healthcare services including skilled nursing, physical therapy, and speech therapy

The Shift from InterQual to MCG Guidelines

Historically, the Pennsylvania DHS relied on the InterQual criteria owned by UnitedHealth Group's Optum division since 2022. However, as of mid-July 2025, the department will fully transition to MCG's state-of-the-art care guidelines for evaluating the medical necessity of the above-mentioned services. This strategic move is expected to streamline processes and reinforce a more patient-centric approach, ensuring beneficiaries receive high-quality care that aligns with best practices in healthcare delivery.

For requests submitted prior to the effective date, reviews will still follow InterQual's criteria, but any new evaluations post-deadline will adhere to the updated MCG standards.

Commitment to Patient-Centered Care

Donna Baker-Miller, Vice President of Government Affairs at MCG, expressed gratitude for being selected as the guiding framework by Pennsylvania's DHS. She reiterated MCG's commitment to driving excellence in patient care across the state's healthcare landscape. By integrating MCG's evidence-based guidelines, Pennsylvania's healthcare providers will not only align with national standards but also enhance their service delivery to meet the needs of their patients more effectively.

MCG's care guidelines have already gained traction across the healthcare sector, being utilized by over 3,000 hospitals and a majority of U.S. health plans, as well as various federal and state agencies including the Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC).

Future Implications

As healthcare policies evolve, this transition to MCG guidelines could set a precedent for other states considering similar reforms. Moving toward an evidence-based approach in assessing medical necessity not only improves consistency and efficiency but also aims to lead to better patient outcomes.

The pension for evidence-based care shows that the future of healthcare in Pennsylvania is headed toward strengthening quality assurance through guided frameworks, thereby fostering a more effective healthcare environment for all.

To learn more about MCG Health and their innovative solutions, visit www.mcg.com.

As the healthcare landscape continues to transform, stakeholders will need to monitor these changes closely and adapt accordingly to ensure the highest standards of care are consistently being met for all beneficiaries.