February 2023

Patient with total knee replacement

Case Study: Total Knee Replacement Inpatient Denial Overturned

Case Study / By

Inpatient stays for procedures commonly done on an outpatient basis can lead to denials. But appealing the denials does have promise. A recent denial for a total knee replacement that was overturned due to the patient’s high risk factors and complex medical history. CLINICAL SUMMARY: Total Knee Replacement A 67-year-old patient underwent a left total […]

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CMS proposed rule change laptop with text

CMS Proposed Rule Changes for MA Patients

Blog, CMS, Length of Stay, Medicare, Utilization Review / By

CMS proposed rule impacts how hospitals determine LOS for MA patients   The Centers for Medicare and Medicaid Services (CMS) recently proposed rule changes (CMS-4201) that could have a significant impact on how hospital utilization management determines level of care for Medicare Advantage patients. The proposed rule1 reflects the agency’s focus on increasing transparency, improving health

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