Case Study: Western Maryland Health System reduces denials and lowers average daily census with Optum InterQual criteria

InterQual Evidence-based Criteria Helps Reduce Denials as Health System Transitions to Value-based Care

Western Maryland Health System (WMHS), a regional rural health system in Cumberland, MD, moved into Maryland’s Total Patient Revenue pilot to shift to value‑based care but was hit by high claim denials that threatened its capitated payments. Despite using InterQual Criteria from Optum, WMHS faced overall denial rates near 5% and an outlier payer denying more than 10%, producing significant financial strain and forcing the system to reassess clinical documentation and admission practices.

Optum’s InterQual was embedded across WMHS workflows—used for physician conversations, staff training, 24/7 ED case manager consultations, discharge planning, and order‑set design—to drive objective, evidence‑based admission decisions and clearer payer communication. As a result, WMHS lowered denials from nearly 5% to almost 2% over three years, reduced its average daily census from a 275‑bed capacity to about 150, and cut unnecessary admissions to improve care value.

Western Maryland Health System

Barry P. Ronan

President and Chief Executive Officer