In a report released March 2 by OIG, investigators found “that most 2019 MA (Medicare Advantage) encounter records contained at least one adjustment code and 55 million of these records contained codes that may indicate the denial of payments by MAOs Medicare Advantage Organizations).” The report’s key take away was that while most of the …
HHS OIG report shows how code adjustments may indicate denials by MAOs Read More »
Inpatient stays for procedures commonly done on an outpatient basis can lead to denials. But appealing the denials does have promise. A recent denial for a total knee replacement that was overturned due to the patient’s high risk factors and complex medical history. CLINICAL SUMMARY: Total Knee Replacement A 67-year-old patient underwent a left total …
Case Study: Total Knee Replacement Inpatient Denial Overturned Read More »
CMS proposed rule impacts how hospitals determine LOS for MA patients The Centers for Medicare and Medicaid Services (CMS) recently proposed rule changes (CMS-4201) that could have a significant impact on how hospital utilization management determines level of care for Medicare Advantage patients. The proposed rule1 reflects the agency’s focus on increasing transparency, improving health …
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 …
Case Study: Type 2 Diabetes and Chronic Kidney Disease Read More »
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, …
Payer prior authorization continues to create roadblocks Read More »
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 …
New UHC Hospital Services Observation and Inpatient Policy takes effect Dec. 1, 2022 Read More »
On a daily basis, hospitals must wrestle with denials for inpatient level of care for patients. An AppriseMD case review physician recently had a successful inpatient denial overturned after completing a Peer-to-Peer with an insurance company medical director regarding a case that involved a patient with asthma and a high BMI. CLINICAL SUMMARY: Asthma and …
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: …
Case Study: Hyperemesis gravidarum 4-day inpatient stay Read More »
A brief denial letter with limited explanation for a complicated case should not be the end of the road for a hospital claim. A recent three-day hospital stay for a patient with a history of breast cancer who underwent a left mastectomy and experienced severe postop complications was denied by the insurance company but then …
A one-day inpatient stay for an elderly patient with a CHADS score of 4 and low EF percentage was overturned after the hospital level of care was discussed in detail during a Peer-to-Peer with the insurance company. The insurance company initially recommended an observation level of care without much explanation, but its physician overturned that …