February 2023

Case study total knee replacement inpatient denial overturned

Case Study: Total Knee Replacement Inpatient Denial Overturned

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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The comment period for the CMS proposed rule changes (CMS-4201) ends Monday, Feb. 13

CMS Proposed Rule Changes for MA Patients

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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