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Case Study: IPO List Proves Critical in Overturning Denied Inpatient Stay

Case Study, Denial Management, Inpatient Only List, Medicare / By

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 […]

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Patient being treated in the hospital

Case Study: Denial Reversed in Short Stay Alcohol-Induced Pancreatitis Admission

Case Study, Denial Management / By

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,

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Compliance with CMS 4201-F pie chart

Medicare Advantage Organization Non-Compliance with The Two-Midnight Rule Findings

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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

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Overnight short-stay denial reversed in AppriseMD case study.

Case Study: Overnight Short-Stay Denial Reversed

Case Study, Denial Management, Length of Stay, Peer-to-Peer / By

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

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Payer Claim Denials & Medicare Advantage Organizations Market Share

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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

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Centers for Medicare and Medicaid Services Final Rule 4201-F timeline

The Impetus Behind the 2024 CMS Final Rule

Blog, CMS, Medicare Advantage, Two-Midnight Rule / By

Arising from concerns that the Medicare Advantage Organizations (MAOs) were delaying and denying services and reimbursement, the Centers for Medicare and Medicaid Services (CMS) implemented 4201-F at the beginning of 2024. This rule was initiated after the publication of a report in April 2022 by the Office of the Inspector General (OIG), a division of

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Case Study: Readmission Linking for Hospital Stays Reversed

Case Study, Denial Management, Peer-to-Peer, Readmission / By

CLINICAL SUMMARY: Recently, physicians admitted a 73-year-old patient with an extensive medical history twice within an 8-day period. The patient required inpatient level of care (LOC) for both hospitalizations. The patient was hospitalized with pneumonia during the first inpatient stay, and the second inpatient hospitalization addressed exacerbated congestive heart failure (CHF). The patient arrived for

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AppriseMD physician advisors provide essential utilization review and denial management education for treating physicians

Case Study: Peer-to-Peer Review of Overlooked Medical Details Can Overturn Denials

Case Study, Denial Management, Medical Necessity, Peer-to-Peer / By

CLINICAL SUMMARY: A 22-year-old patient, four weeks postpartum, arrived in the emergency department suffering from abdominal pain and nausea. An ultrasound revealed the common bile duct was dilated to 8 mm, and a CT scan showed gallstones. In addition to steatosis, the patient also had a positive Murphy’s sign. Lab tests performed during the patient’s

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Case Study: Two-Midnight Rule Helps Overturn Medicare Advantage Plan Inpatient Denial

Case Study, Denial Management, Medicare, Peer-to-Peer / By

CLINICAL SUMMARY: Two-Midnight Rule Helps Overturn Medicare Advantage Plan Inpatient Denial   A 68-year-old patient with an extensive medical history arrived at the emergency room after three days of acute gastrointestinal (GI) bleeding. The patient experienced nausea and observed bright red stool blood that persisted. The patient’s medical history included atrial fibrillation treated with an

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