AppriseMD

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, […]

Payer Prior Authorization Continues to Create Roadblocks Read More »

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

New UHC Hospital Services Observation and Inpatient Policy Takes Effect Dec. 1, 2022 Read More »

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:

Case Study: Hyperemesis Gravidarum 4-day Inpatient Stay Read More »

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

Without Proper Documentation, Inpatient Denials are Often Upheld Read More »

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

Medicare Appeals Process Needs to be Amended Read More »

Determining observation stay guidelines

Which Guidelines Should Hospitals Follow for an Observation Stay?

Blog, Length of Stay, Utilization Review / By

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

Which Guidelines Should Hospitals Follow for an Observation Stay? Read More »

Medical chart documentation

Case Study: Hospital Stay Due to Injury and Complex Medical History

Case Study / By

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

Case Study: Hospital Stay Due to Injury and Complex Medical History Read More »

Scroll to Top