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Denial Management
Revenue Integrity Insights

A Collection of White Papers from AppriseMD

New from AppriseMD

Is your hospital losing money over the weekend?

The impact of weekend utilization review on reimbursement

It’s common to find hospital utilization management teams and physician advisory staffing lower during weekends. Lower staff levels can lead to delays in patient determinations that ensure treatment is at the appropriate level of care (LOC). Staffing issues can also stall discharges, keeping patients in the hospital even though they are ready to leave. Both scenarios can negatively impact quality of care, the patient experience, and hospital resources. Prolonged hospital stays have been linked to an increased risk of hospital-acquired infections and
other complications, while poor triage and discharge processes impact patient satisfaction scores (HCAHPS). All of these have financial ramifications that should be mitigated.

Implementing the 2024 CMS Final Rule:

Five Points of Focus for Utilization Review Teams

Although this is new territory for MAOs, at AppriseMD we believe under the Center for Medicare and Medicaid Services’ (CMS) new Rule 4201-F, MA patients will eventually be treated the same as Traditional Medicare patients given CMS’s standard and the considerable support by hospitals, physician advisors, and the America Hospital Association.
It may take time for the complete change to happen. Some MAOs will not comply. Some will try and get it wrong. Some will comply and get it right. We’ve outlined five important points utilization review teams and physician advisors should focus on moving into 2024 as the rule implementation takes shape.

Turning UM Data into Revenue Opportunities

Exploring the balance between cost and care

Utilization management (UM) data analysis transforms revenue cycle and care management practices, yielding greater earnings to support hospital and health system operations and sustainability while improving the timely delivery of quality care.

UM balances the delivery of the right care at the right time in the right setting. Providing the right, or medically necessary care, depends upon providing patients with treatment needed to achieve the best possible medical outcome without over- or under-utilizing services. The complexity of the cost structure in the U.S. healthcare system adds another hurdle. Even though medical necessity is the foundation upon which UM rests, it does not exist in a vacuum. It is intricately linked to cost. Achieving a utilization management balance can improve a hospital’s quality of care while at the same time reducing costs.

Beyond the pandemic, Part 1 sicker patients and longer stays, a compendium of research from AppriseMD

Beyond the Pandemic

Part 1: Sicker Patients and Longer Stays, a compendium of research by AppriseMD

Part 1

In 2020, hospitals encountered a crisis unlike any they had faced before. More than two years later, hospitals are still coping with the repercussions of the COVID-19 pandemic both in terms of patient volumes and financial challenges.

In 2021 and 2022, as COVID-related illnesses waned, the average length of stay (ALOS) and patient acuity continued to increase across the U.S. as hospitals began to see sicker patients due to an extended period of delayed care. This new trend emerged as pent-up demand for elective procedures increased and spikes in hospitalizations continued to cycle in the fall of 2022 due to things like new COVID variants and a respiratory syncytial virus (RSV) outbreak. Understanding the changes caused by the pandemic, their root causes and their impact on hospitals is critical in building strategies that will help hospitals address the trends.

DownloadPart 1

Dealing with denials, a compendium of research by AppriseMD

Dealing with Denials

An in-depth look at the causes of inpatient denials and what healthcare organizations can do to keep them from happening.

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Ultimately hospitals and other healthcare providers can no longer ignore the impact inpatient denials can have on their cash flow. Ninety percent of all denials are preventable, so why aren’t more denials being prevented? If an organization takes a focused and unremitting approach to tackling this problem, it can see improvements in lowering denials and increasing overturned denials. This approach requires persistence and commitment to proper documentation, plus a clear utilization review strategy together with a team approach. The result will help support the financial health and future sustainability of the organization.

Download the paper.

Beyond the Pandemic, Part 2 How Hospitals Can Adapt to the New Reality

bEYOND THE PANDEMIC

Part 2: How Hospitals Can Adapt to the New Reality, a compendium of research by AppriseMD.

Part 2

As the pandemic recedes, the average length of stay continues to increase nationwide despite a drop in COVID-related illnesses. The American Hospital Association* reported that the average patient length of stay increased by 19.2% in 2022 compared to pre-pandemic levels. A combination of factors was responsible for this change. It is clear hospitals will continue to face challenges in 2023. Understanding the residual effects caused by the pandemic, their root causes, and their impact on the continuum of care, is critical to building strategies to effectively manage hospital capacity and resources. 

In Part 2 of our compendium of research, we look at strategies to bend hospital utilization curves by right sizing length of stay as well as keys to addressing post-disc.

Download Part 2

Optimize patient care, reduce denials and maximize reimbursement through our unique approach to achieving excellence in utilization management.

Discuss your hospital’s utilization and denial management needs with our team.

 

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