AppriseMD

Review for Denied Inpatient Hospital Stays

Case Study: Denied Inpatient Stay Due to Suicidal Ideation and Drug Overdose Overturned

Case Study / By

A recent case reviewed by AppriseMD showed a good example of how a case that on the surface appears inpatient appropriate can still be denied by the insurance company and overturned on peer-to-peer (P2P). Oftentimes a level-headed conversation with the insurance company will lead to the correct outcome. The case involved a drug overdose and […]

Case Study: Denied Inpatient Stay Due to Suicidal Ideation and Drug Overdose Overturned Read More »

Case Study bilaterial pneumonia denial overturned

Case Study: Bilateral Pneumonia

Case Study / By

CLINICAL SUMMARY: Bilateral Pneumonia A 23-year-old nonverbal female patient arrived in the emergency department with her parents who said she had a fever and heavy breathing since the morning. The patient’s medical history included Lennox-Gastaut Syndrome, severe mental retardation, seizure disorder, recurrent aspirations, recurrent pneumonia and vagal nerve stimulator. Her parents said she had been

Case Study: Bilateral Pneumonia Read More »

AppriseMD physician advisors provide essential utilization review and denial management services to hospitals

How Does the Two-Midnight Rule Apply When a Traditional Medicare Patient Has No Safe Discharge Plan?

Blog, Length of Stay, Medicare / By

For a traditional Medicare patient admitted for observation, it is not uncommon to remain in the hospital longer than two midnights due to non-medical reasons including waiting for a transfer to another facility or family situations. In these cases, the reason the patient remains hospitalized is the lack of a safe discharge plan. Should such

How Does the Two-Midnight Rule Apply When a Traditional Medicare Patient Has No Safe Discharge Plan? Read More »

CS-chest-pain-non-cardiac denial overturned

Case Study: Chest Pain, Non-cardiac Can be Difficult to Get Admission Status Correct

Case Study / By

Chest pain is one of the most common ER diagnoses. For those patients who require hospital admission, getting the admission status correct and paid by the insurance company can be tricky. One such case involved a patient who arrived in the ER with chest pain presumed due to unstable angina (TIMI 3). The patient was

Case Study: Chest Pain, Non-cardiac Can be Difficult to Get Admission Status Correct Read More »

Doctors in surgery, CMS to keep inpatient only list

CMS to Keep the Inpatient Only List

Blog, Inpatient Only List, Length of Stay, Medicare / By

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,

CMS to Keep the Inpatient Only List Read More »

Administrative law judge reviews appeals at the highest level

Appealing Denials through the Medicare Claims Appeals Process Works

Blog, Inpatient Only List, Length of Stay, Medicare / By

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

Appealing Denials through the Medicare Claims Appeals Process Works Read More »

ehr, emr, electronic medical record graphic

Good Documentation can Reduce Hospital Admission Denials

Blog, Length of Stay, Utilization Review / By

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

Good Documentation can Reduce Hospital Admission Denials Read More »

Scroll to Top