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Several factors and considerable feedback led CMS to keep the inpatient only list

The Centers for Medicare and Medicaid Services’ decision to not eliminate the inpatient only list (IPO) was due to the numerous comments and feedback it received from the medical community, the COVID-19 public health emergency and the fact that the change “transpired quickly,” according to the final rule (CMS-1753FC) issued in December.1 Heading into 2022, …

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Appealing denials through the Medicare Claims Appeals Process works

Though it took time and effort, an administrative law judge ruled in favor of a client hospital and overturned a Medicare claim denial for a total knee replacement surgery. The hospital can now fully recover the cost of that surgery, with interest. The case dates back to 2015 when a traditional Medicare patient underwent a …

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Good documentation can reduce hospital admission denials

We all know in clinical medicine that documentation is everything. Hence the old saying “If it’s not documented, then it didn’t happen.” This is particularly true outside of the clinical realm in the insurance world. Level of care is based on the clinical condition of the patient, how they present and how that meshes with …

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Rightsizing Length of Stay

Reducing Avoidable Hospital Inpatient Days   Hospitals working to improve efficiency by rightsizing length of stay and reducing avoidable hospital inpatient days must implement a process that begins prior to admission and extends beyond discharge. Extended hospital stays beyond what is needed for high quality care and avoidable readmissions, can be associated with an increased …

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Should hospitals pursue appeals of Medicare denials?

Hospital executives and case review managers should soon see the back-logged appeals process speed up for denied Medicare claims. That means hospitals now have one less reason not to pursue appeals of Medicare denials. According to attorney Knicole C. Emanual, writing for RACmonitor, The Centers for Medicare and Medicaid Services (CMS) has given The Office …

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Eliminating the CMS inpatient only list will continue to complicate hospital stays

For an update on this issue, please read: CMS reverses course in inpatient only list   The Centers for Medicare & Medicaid Services (CMS) has begun to dismantle its inpatient only list, which has directed the level of care for more than 1700 procedures for physicians and hospitals since 2000. CMS said the move gives physicians …

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Utilization Review: In-house or Outsource?

Utilization management programs are often in-house services provided by hospital staff. However, more and more hospitals are outsourcing utilization review management as the pressure mounts to contain costs, especially following the COVID-19 pandemic, and improve care. Hospitals benefit from outsourcing utilization review in several ways, as it can: Free up in-house physician advisors and chief …

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Documentation – A Key for Reduced Denials

There is one relatively easy way hospitals can reduce claims denials: better clinical documentation. Insurance companies require documentation, and it is often the leading factor in level of care and admission denials. The importance of providing complete documentation never goes away. Treating physicians and utilization review managers must ensure that every admission includes: All the …

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A quiet shift that could shake up hospital Utilization Review

There is a seismic shift happening in Utilization Review: As of Saturday, May 1, 2021, UnitedHealthcare, the country’s largest healthcare insurance provider, is changing guidelines to adjudicate the level of care cases for hospitals from Milliman Care Guidelines (MCG) to InterQual.1 AppriseMD will be working closely with our current hospital clients to ensure this is …

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Outpatient Arthroplasty Surgery: A Position Paper from AppriseMD

The American Association of Hip and Knee Surgeons have stated that hip and knee replacements can be safely performed in the outpatient setting in some specific circumstances. However, the wording implies the procedure is most appropriate in an ideal patient when performed in a facility and by a surgical team specifically equipped for this type …

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