Hospitals continue to face payer denials throughout the revenue cycle, including technical and administrative denials, as well as coding denials where Diagnostic Related Group (DRG) downgrades are a major pain point. Clinical denials are also rampant, whereby the payers are challenging the clinical judgement of providers despite clear evidence that, for example, inpatient level of care (LOC) is warranted. While provider hospitals are requesting peer-to-peer (P2P) reviews with the payers, some of these cases are not overturned.
THE SOLUTION
When P2P payer reviews are upheld, hospitals are left with two choices: forgoing reimbursement dollars to get paid promptly or initiate a formal appeal to overturn the denial. While the later option delays payment, AppriseMD believes it is the best way forward. Appropriate reimbursement is vital to all providers, and establishing a consistent process to capture all earned revenue is pivotal for optimizing the revenue cycle. For hospitals looking to outsource this function or to assist with overflow, AppriseMD can help.
PAYER DENIAL CASE STUDY SUMMARY
A Medicare Advantage (MA) payer denied inpatient reimbursement following a P2P. The case involved a 57-year-old patient with complex medical issues including morbid obesity, diabetes, hypertension, heart failure, and Pickwickian Syndrome. The patient was initially sent to the Emergency Department because of a failing BiPAP machine but was admitted for treatment of a urinary tract infection, constipation, congestive heart failure, hyponatremia and hyperglycemia, all of which required more than two midnights of hospital care. Despite these findings, the MA medical director maintained that the patient did not meet the criteria for any of the diagnosis under review.
FORMAL APPEAL SUMMARY
AppriseMD’s physician advisor recommended pursuing a formal appeal based on the clinical complexity and the objective data in the case.
The written appeal highlighted multiple factors, including the patient’s dependence on a BiPAP machine, treatment for ESBL UTI with IV antibiotics, uncontrolled blood sugar levels necessitating frequent insulin adjustments, worsening kidney function, and severe constipation. Further, AppriseMD included the statement that the continued care provided for the patient could not have been safely administered in the outpatient setting even though the hospital attempted to treat her in observation status.
Additional information provided by AppriseMD cited the Center for Medicare and Medicaid’s (CMS) Two-Midnight Rule, highlighting that the denial was inconsistent with CMS guidelines and MA plan requirements. Following receipt of this well-documented clinical summary that included regulatory guidelines, the payer reversed their position.
THE RESULT
The hospital received full reimbursement of the DRG after AppriseMD overturned the denial during the formal appeal process, with no additional work placed on the hospital staff. AppriseMD offers this service on a contingency basis, so hospitals are not billed for any work performed that does not result in reimbursement.
THE CHALLENGE
