CLINICAL SUMMARY: A 73-year-old patient’s primary care doctor sent her to the Emergency Department (ED) after multiple labs taken for continuing chest pains showed abnormal results. The patient, who had been suffering chest pain for more than a week and who was taking nitroglycerin, had a stent placed in April. The patient had an extensive […]
Case Study: Medical Necessity and Reasonable Expectations Read More »
CLINICAL SUMMARY: An 88-year-old patient with a complex cardiac history of chronic congestive heart failure and dilated cardiomyopathy arrived at the emergency department (ED) with worsening shortness of breath and intermittent dizziness. The patient’s medical history included COPD, dilated cardiomyopathy, ventricular tachycardia with implantable cardioverter-defibrillator (ICD) shocks, atrial fibrillation (for which the patient uses Eliquis®),
Case Study: Physician Advisor Secondary Review Insight on MA Case Read More »
An American College of Physician Advisors’ (ACPA) recent report concurs with earlier data from AppriseMD that many Medicare Advantage Organizations (MAOs) are not complying with the guidelines that the Centers for Medicare and Medicaid Services established under rule 4201-F. In its News to Note from July 20241, the ACPA looked at whether all of the
Missing adequate weekend assessments exposes up to 29% of hospital days to potential payment issues. Physicians consider many factors during the complex clinical judgement used in determining a hospital admission. Many hospitals operate with reduced staffing on the weekends, and this can have a significant impact on reimbursement when factoring that weekends encompass approximately 105
The Financial Impact of Weekend Utilization Review Read More »
CLINICAL SUMMARY: Doctors performed a scheduled hysteroscopy with dilation and curettage (D&C), endocervical myomectomy and MyoSure polypectomy on a 55-year-old patient who had been experiencing abnormal uterine bleeding with cervical fibroids and an endometrial polyp. The patient had a medical history which included pancreatitis due to alcoholism with a pseudocyst, deep venous thrombosis, hypertension, pleural
Case Study: IPO List Proves Critical in Overturning Denied Inpatient Stay Read More »
As the use of artificial intelligence (AI) in healthcare claims management widens, the importance of careful oversight is needed. Any use of automation for claim denials should be scrutinized by providers to ensure the denial is appropriate. A recent Healthleaders report asked a key question all revenue cycle managers must consider: What is the balance
Payers, Artificial Intelligence and Revenue Cycle Read More »
CLINICAL SUMMARY: A 30-year-old patient arrived at the emergency room suffering from abdominal pain, nausea and vomiting. The patient’s symptoms had been occurring for the past six weeks and progressively worsened. The patient complained of pain in the upper abdomen that radiated to the back. The patient had a medical history of anxiety, asthma, depression,
Case Study: Denial Reversed in Short Stay Alcohol-Induced Pancreatitis Admission Read More »
AppriseMD hospital utilization review data for the first two months of 2024 shows that Medicare Advantage Organizations (MAOs) are denying claims that would have been approved under Traditional Medicare. BACKGROUND MAOs must adhere to the same guidelines as Traditional Medicare as per the Center for Medicare and Medicaid Services’ (CMS) 2024 rule 4201-F. MAOs can
Medicare Advantage Organization Non-Compliance with The Two-Midnight Rule Findings Read More »
CLINICAL SUMMARY: A 50-year-old patient was hospitalized overnight after arriving in the emergency room with constant left flank pain. The patient was seen in the emergency room (ER) the previous week with similar symptoms, which doctors diagnosed as a 5 mm, left proximal ureteral stone with mild hydroureteronephrosis. The patient was treated and sent home
Case Study: Overnight Short-Stay Denial Reversed Read More »
Medicare Advantage (MA) plans traditionally implement more restrictive medical necessity requirements than Traditional Medicare. They also produce a higher denial rate than all other payer categories combined, according to Crowe. This leaves hospitals investing more time and resources into ensuring appropriate reimbursement. MA plans already account for a generous portion of Medicare plans in the US, and
Payer Claim Denials & Medicare Advantage Organizations Market Share Read More »