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Which guidelines should hospitals follow for an observation stay?

Both national evidence-based guidelines and insurance company guidelines factor into level of care determination.   When it comes to determining a patient’s level of care for a short hospital stay, observation services are generally used for short-term monitoring, testing and evaluation to establish a treatment plan, and to give the treatment team time to see …

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Case Study: Hospital stay due to injury and complex medical history

According to the CDC’s National Center for Health Statistics*, there are 130 million visits a year to Emergency Departments, 35 million of which are injury related. Many injury-related ER visits do not result in admission to the hospital, but for those that do, hospital utilization review managers need to provide insurance companies sufficient documentation showing …

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Case Study: Alcohol withdrawal and AMA departure can still qualify as inpatient stay

Does leaving the hospital against medical advice (AMA) equal an outpatient short stay? Not necessarily. AppriseMD reviewed one inpatient denial case involving a patient who left the hospital AMA after a two-day stay due to severe alcohol withdrawal and seizures. The AppriseMD physician reviewer was able to overturn the denial after a discussion with the …

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Case Study: Alcohol withdrawal inpatient stay denial overturned based on care required

Alcohol withdrawal and a positive COVID infection resulted in an inpatient hospital stay for one patient; however, the insurance company denied the short stay. A detailed peer-to-peer discussion of this case with the insurance company overturned the denial based on the acute symptoms and the medical and supportive care required. CLINICAL SUMMARY: Alcohol Withdrawal A …

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Justice Department files antitrust lawsuit against UnitedHealth to stop Change Healthcare acquisition

The United States Department of Justice filed an antitrust lawsuit earlier this year aiming to stop UnitedHealth Group from acquiring Change Healthcare.1 Hospital CFOs and utilization review managers have much to watch in this case related to how it could not only impact competition in the markets but how it could impact the guidelines used …

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AHA’s advocacy of rural hospital issues is needed

The American Hospital Association (AHA) updated rural hospital leaders regarding its 2022 Rural Advocacy Agenda during the recent AHA Rural Health Care Leadership Conference in Phoenix, AZ, attended by AppriseMD CEO Franklin E Baumann, MD. “The 2022 Rural Advocacy Agenda focuses on broader, forward-looking legislative and regulatory priorities that are not necessarily connected to the …

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Case Study: Multiple Sclerosis inpatient stay denial upheld

Determining level of care as a live case review can be difficult when doctors are still waiting on imaging and deciding upon treatment plans. One such live case review involved a patient with multiple sclerosis as detailed here, which AppriseMD recommended for inpatient level of care. The insurance company denied the inpatient stay. After completing …

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Case Study: Chest Pain, Unstable Angina P2P reveals intricate case

Patients admitted to the hospital with chest pain and other significant findings in the ER can still be denied for inpatient stay by insurance companies. One case involving a patient with severe stenosis of the right coronary artery and another critical lesion shows how an initial denial by the insurance company can be overturned after …

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Case Study: Acute diverticulitis stay denied

Healthcare insurance companies often deny inpatient hospital stays if the information provided does not show intensity of services significant enough to need inpatient care. If the patient’s care is more intense than the medical record implies a Peer-to-Peer discussion can provide more critical information to the insurance company. CLINICAL SUMMARY: Acute Diverticulitis A 69-year-old female …

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Case Study: Post C-section wound infection and asthma exacerbation denial overturned

A recently denied inpatient hospital admission for asthma exacerbation and wound infection was overturned when the insurance company was made aware of additional symptoms that doctors deemed high risk and worthy of a higher level of care. Clinical information sent by the hospital to the insurance company did not show the need for the extra level …

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