Supporting empathy and transparency in patient communications

Inappropriate care decisions continue to burden the healthcare system, as underscored by one study that discovered over $75.7 billion in waste due to overtreatment and low-value care.¹ Another study found that more than one-third of adults over the age of 65 in the U.S. often receive medications that are not medically necessary.²

Medical necessity determinations — decisions about whether care or treatment is clinically necessary based on the latest research and literature — can be guided by the evidence-based InterQual® Criteria, which support safe, effective and appropriate care tailored to each patient’s clinical situation. As part of the utilization management process for cases not meeting initial criteria review, medical directors evaluate the patients’ clinical scenarios, identify clinical exceptions, make final medical necessity determinations and then communicate these decisions to patients.

Communicating medical necessity determinations is a continuous, coordinated and multistep process that requires thorough documentation and a system of checks and balances to ensure decisions are delivered to patients in a clear, personalized and compassionate way. It is important for patients to understand the decisions that impact their care — not just in clinical terms, but in language that conveys empathy, acknowledges their concerns and empowers them with clear next steps based on what care is considered necessary, why and how that decision was made.

Navigating this intricate process frequently presents a significant challenge for healthcare organizations. There are an increasing number of regulatory and accreditation requirements — from CMS, states, NCQA, URAC and more — for how communications should be managed, with the expectation of timely and transparent information sharing. Although some details vary, there are common themes within these requirements:

• Written communication should provide a general reason for the decision as well as a specific clinical reason.
• It should refer to the criteria and policies used to inform decision-making.
• It should provide the patient with an understandable explanation and details on how to appeal or get more information.

We have heard from customers that building and maintaining a content library aligned with consumer preferences and compliance standards is time-consuming and often leads to inconsistent communication. To help meet this challenge, our InterQual content development team created Decision Reasons, a tool designed to transform how organizations communicate decisions grounded in the best available clinical literature.

Built on the foundation of the evidence-based InterQual Criteria and industry content such as Medicare, Decision Reasons provides a library of detailed, empathetic and comprehensible statements that explain the rationale behind a medical necessity determination.

Decision Reasons emphasizes clinical rigor and consumer centricity. Each statement is carefully crafted to align with the specific evidence-based InterQual Criteria used to inform the determination, while also being written in a way that's easily understandable for members, at a 5th to 7th grade reading level. This ability to seamlessly combine clinical accuracy with consumer-friendly language is a key strength of Decision Reasons.

Decision Reasons also allows reviewers to incorporate patient-specific clinical details directly into the language, ensuring that each communication is not only accurate but personalized. This customization is critical in helping patients feel seen and respected.

Whether it’s an inpatient admission, a piece of equipment or a procedure, the goal of Decision Reasons language is to help patients understand what was requested on their behalf and whether a more appropriate alternative exists.

An example of effective application of Decision Reasons language is one that clearly outlines the rationale for an adverse determination of acute level of care while simultaneously conveying a more suitable alternative — such as observation-level care. Communication would begin by educating the patient on the distinctions between levels of care, establishing a foundation for understanding the decision. It would then clearly and empathetically articulate how the care the patient received, while necessary, did not align with the criteria for acute inpatient admission.

The development of Decision Reasons has been deeply collaborative. We engaged with payer and provider customers and, most importantly, consumers. We conducted live feedback sessions using real-world scenarios and draft communications, and the feedback was encouraging. As hypothesized, patients responded positively to letters that were clear, respectful and informative.

One participant shared, “[This communication] made me feel that the insurance company is professional and courteous. They explained why, which is big.” Another said, “This explains the reasoning behind the decision and is very thorough… Pretty perfectly detailed, lots of information, everything I’d want to see.”³

Importantly, we’ve also authored Decision Reasons language to help communications convey respect for the care provided and avoid implying any judgment about its quality.

This iterative process has allowed us to continuously refine the language and ensure that the tool remains aligned with clinical best practices and patient expectations in a dynamic healthcare environment. Our consumer content has been recognized by URAC with the Health Content Provider Certification, affirming our commitment to delivering quality content that is both evidence-based and consumer-safe.

Decision Reasons streamlines workflows, reduces the burden of drafting custom patient communications and helps maintain communication consistency across teams. It also supports compliance with regulatory standards and enhances the overall patient experience. But importantly, it reinforces a culture of empathy and transparency. In a system where trust can be challenging, every interaction matters. And when patients receive communications that are clear, compassionate and comprehensive, it builds credibility — not just for the organization, but for the healthcare system as a whole.

As we continue to expand Decision Reasons across more InterQual Criteria and industry content, our focus remains the same: to support organizations in delivering care that is not only clinically appropriate but also patient centered.