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Medicare Advantage 2023 enrollment by payer

Payer Claim Denials & Medicare Advantage Organizations Market Share

CMS, Medicare Advantage / By

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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Linking hospitalizations AppriseMD

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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Two-midnight rule helps overturn denial

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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Doctor visits patient post-surgery in the hospital.

Case Study: Post-Surgery Inpatient Admission Denial Overturned

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

CLINICAL SUMMARY: Post-Surgery Inpatient Admission Deemed Medically Unnecessary Overturned A 52-year-old patient underwent a planned ventral incisional hernia operation, performed laparoscopically using an intraperitoneal onlay mesh placement. The patient was classified as ASA Class III, defined by the American Society for Anesthesiologists (ASA) for patients with “severe systemic disease that is not incapacitating” with a

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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

Case Study, Denial Management / By

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

Case Study, Denial Management, Inpatient Only List / By

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

Case Study, Discharge, Utilization Review / By

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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