AppriseMD

Physician advisors with hospital-based clinical experience combined with utilization management experience, can bring when it comes to reversing short stay denials.

Case Study: Medical Necessity Behind Short Stay is Key

CLINICAL SUMMARY: Medical Necessity Behind Short Stay is Key This case involves a one-day inpatient denial for a 30-year-old patient treated for acute pancreatitis. With abdominal pain and nausea, the patient went to the Emergency Department where he was found to have upper abdominal pain and tenderness, a lipase of 1,447 U/L (reference range 16-77 …

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Physicians in operating room

Case Study: TKA Inpatient Status Denied Despite Being on CMS Inpatient Only List

Insurance companies are more likely to approve inpatient status for surgeries included on the CMS Inpatient Only List (IPO). Total knee replacements and total hip replacements are two common procedures on the IPO list. A Peer-to-Peer review can help reverse a denial for a inpatient stay for these types of cases. CLINICAL SUMMARY: TKA Inpatient …

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patient in wheelchair

Case Study: Inpatient Denial Overturned for Elderly Patient with Significant Risk Factors

Inpatient denials for elderly patients on Medicare Advantage plans can appear hard to refute due to the criteria laid out by CMS and health plans. However, significant risk factors such as prior recent strokes and urinary tract infections, especially in older patients, are reason enough to attempt to reverse the initial denial. See one case …

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Hospital hallway with wheelchairs for discharge

Case Study: Awaiting Discharge to Skilled Nursing Facility

Extended hospital stays where a patient is medically ready to discharge but awaiting admission into a Skilled Nursing Facility or Acute Inpatient Rehabilitation continues to be an issue and can lead to revenue loss. AppriseMD recently overturned an inpatient denial for an 11-day hospital stay that was extended awaiting discharge. CLINICAL SUMMARY: Awaiting discharge to …

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Diabetic patient testing blood

Case Study: Poorly Controlled Diabetes Inpatient Denial Overturned

Hospital utilization management requires constant communication between the utilization management team and physician advisors as well as continuously reassessing observation cases for possible conversion to inpatient status. Missing these opportunities leads to increased observation rates, reduced revenue, and potential Patients requiring ongoing medical care beyond the observation period should be constantly reassessed for inpatient status …

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patient sitting alone in hospital room

Case Study: Type 2 Diabetes and Chronic Kidney Disease

Even with concerns about days spent waiting on a transfer to a higher level of care, an insurance company medical director reversed an inpatient stay denial after a Peer-to-Peer discussion of the case. CLINICAL SUMMARY: Type 2 Diabetes and Chronic Kidney Disease A 40-year-old patient arrived in the Emergency Department complaining of worsening right upper …

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Payer Prior Authorization Continues to Create Roadblocks

Doctors surveyed by the American Medical Association said the payer prior authorization (PA) process creates delays in care, abandoned treatments, and impacts outcomes. The complexity and inconsistencies of payer PA processes continue to create roadblocks to care for both patient and providers, including hospitals. Although the American Medical Association, along with the American Hospital Association, …

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checking armband

New UHC Hospital Services Observation and Inpatient Policy Takes Effect Dec. 1, 2022

UnitedHealthcare’s Observation Utilization Review Guide is sunsetting and will be replaced by the new Hospital Services: Observation and Inpatient Policy1. The change takes effect Dec. 1, 2022, for commercial, community and exchange plans. The new policy explicitly mentions InterQual, stating “InterQual criteria are intended to be used in connection with the independent professional medical judgment …

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Case study hyperemesis gravidarum 4-day inpatient stay

Case Study: Hyperemesis Gravidarum 4-day Inpatient Stay

After overturning a four-day inpatient denial for a 13-week pregnant patient with hyperemesis gravidarum and severe pain, the insurance company medical director commented that it is very difficult to overturn these cases. Just another example of the importance of detailed follow-up Peer-to-Peer discussions, even in denied cases that seem “hopeless” to be overturned. CLINICAL SUMMARY: …

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