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Physician advisor managing the formal written appeal process

Case Study: Managing the Formal Written Appeal Process

Appeal Management, Case Study, Formal Appeal, Medicare Advantage, Two-Midnight Rule / By

THE CHALLENGE In 2025, inpatient (IP) and outpatient healthcare claim denials increased by 12% and 14% respectively and the average amount per claim increased by 18%1, forcing hospitals to address payer denials head-on. Most health systems deploy a multi-prong approach to ensure appropriate reimbursement, including outsourcing at least a portion of their revenue cycle operations.

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Physician advisor appeals Medicare Advantage denial to skilled nursing facility.

Case Study: Untapped Potential for Hospitals, Appealing MA Denials to Skilled Nursing Facilities

Appeal Management, Case Study, Discharge, Medicare Advantage / By

THE CHALLENGE LA recent report identified prior authorization request denials by Medicare Advantage Organizations (MAOs) for post-acute care to be a particular area of concern. The report, published by the Department of Health and Human Services Office of Inspector General (HHS-OIG), raised concerns that the MAOs may be inappropriately denying care, evidenced by the 95%

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Physician advisor reviews a lower level of severity determination after engaging in a severity discussion.

Case Study: High Severity Reimbursement Approved Following Severity Discussion

Case Study, Level of Care / By

THE CHALLENGE Last year, several payers implemented or announced some tactical changes in their provider reimbursement policies. The providers took a hit with these evaluation and management (E/M) downcoding programs, resulting in lower-tier payments to providers if the payers disagreed with the severity of the patients’ illnesses. Regulatory review has sidelined the rollout of some

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For hospitals, high-level severity denials are a major challenge resulting in increased administrative, clinical and financial burdens.

Case Study: Underpayment Determination Reversed Following Severity Discussion

Case Study, Level of Care, Two-Midnight Rule / By

THE CHALLENGE For hospitals, high-level severity denials are a major challenge resulting in increased administrative, clinical and financial burdens. One major concern is the dodging of the Two-Midnight rule, which was finalized under CMS-4201-F in April of 2023. The Two-Midnight rule sets the precedent that patients are appropriate for inpatient admission if the admitting physician

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Case study reviews level of care severity

Case Study: Inpatient Level of Care Payment Review Reversed After Peer-to-Peer

Case Study, Level of Care, Peer-to-Peer / By

THE CHALLENGE Many hospitals and health systems have been forced to navigate a new payer tactic that does not result in a formal denial of inpatient (IP) level of care (LOC). Instead, the payer affirms that IP admission was medically necessary, but reimbursement is reduced due to a perceived lack of severity for the billed

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Formal written appeals of an upheld peer-to-peer

Case Study: Formal Appeal Overturns Upheld Peer-to-Peer

Case Study, Denial Management, Formal Appeal, Peer-to-Peer / By

THE CHALLENGE 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

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Patient on machine in hospital.

Case Study: Challenging MA Denial Overturned Despite One-Midnight Stay

Case Study, Two-Midnight Rule / By

CLINICAL SUMMARY: A 76-year-old female arrived at the emergency department critically ill, experiencing palpitations and shortness of breath. The patient had a complex medical history including ovarian and thyroid cancers, chronic heart failure (CHF) with reduced ejection fraction (EF 20%), stage 3b chronic kidney disease, gastroesophageal reflux disease, paroxysmal atrial fibrillation (A-fib) on anticoagulation, type 2

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infant failure to thrive in pediatric unit

Case Study: Infant Failure to Thrive Inpatient Denial Overturned

Case Study, Medicaid, Peer-to-Peer / By

CLINICAL SUMMARY: A newborn infant, just over one-month-old, arrived at the Emergency Department (ED) under the direction of a pediatrician, who was concerned about lack of weight gain since birth. The infant was born weighing 8 pounds, 5 ounces and weighed 8 pounds, 5.5 ounces one month and five days after birth. The patient’s weight

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payment policy for hospitals balancing cost and care

Understanding Aetna’s New Level of Severity Inpatient Payment Policy

Blog, Payers / By

Hospitals and health systems across the country are preparing for a significant shift in how Aetna reimburses certain inpatient stays. Aetna’s Level of Severity Inpatient Payment Policy, which went into effect January 1, 2026, (updated from the original effective date of November 15, 2025) introduced a new framework for evaluating and reimbursing urgent or emerging

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