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Diabetic patient testing blood

Case Study: Poorly Controlled Diabetes Inpatient Denial Overturned

Case Study, Denial Management / By

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 and reduced revenue. It can also lead to patients potentially requiring ongoing medical care beyond the observation period. Such patients […]

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patient sitting alone in hospital room

Case Study: Type 2 Diabetes and Chronic Kidney Disease

Case Study / By

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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hospital admissions sign

Payer Prior Authorization Continues to Create Roadblocks

Payers, Utilization Review / By

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

Observation and Inpatient Policy, Payers, Utilization Review / By

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

Case Study / By

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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without proper documentation inpatient denials are often upheld

Without Proper Documentation, Inpatient Denials are Often Upheld

Denial Management, Utilization Review / By

Peer-to-peer discussions between hospital physicians – or their physician advisors – and the insurance company’s medical director can often overturn inpatient denials. But without proper documentation they do not work to rescind denials. Proper documentation must include an assessment coinciding with a detailed treatment plan updated throughout hospitalization. AppriseMD recently recommended to appeal a case

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Medicare Appeals Process Needs Changes

Medicare Appeals Process Needs to be Amended

Appeal Management, Denial Management, Medicare / By

In her recent article, “Ghosting the Medicare Provider Appeals Process,” Knicole C. Emanuel Esq. argues that the process by which denied Medicare claims are reviewed and appealed is counter to rest of the U.S. legal system. The lengthy process for addressing denied Medicare claims is multi-tiered and, until recently, hampered by a years-long backlog due

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