THE CHALLENGE
Last year, several payers implemented or announced some tactical changes in their provider reimbursement policies. The providers took a hit with these evaluation and management (E/M) downcoding programs, resulting in lower-tier payments to providers if the payers disagreed with the severity of the patients’ illnesses. Regulatory review has sidelined the rollout of some E/M overcoding or downcoding programs, but it has not stopped the payers from issuing lower level of severity (LLS) determinations, allowing the payers to circumvent the traditional denial pathway.
When a payer issues an LLS determination, the stay is approved under an inpatient (IP) level of care (LOC), however the reimbursement is more closely aligned to an observation LOC rate. This makes it more difficult for revenue cycle teams to identify an LLS decision as a reimbursement denial since the payer authorizes the IP LOC stay. Further, this allows the Medicare Advantage (MA) plan to present an LLS determination as a billing adjustment, avoiding any federal oversight that could otherwise negatively impact the plan’s Medicare Star Rating.
THE SOLUTION
AppriseMD delivers physician-driven, data-informed decision-making, and our physician advisors take an aggressive approach when it comes to maximizing reimbursement. As a physician-driven company, we believe in the value that clinicians provide daily, and we work hard to safeguard our clients’ reimbursement so that they can continue providing exceptional care. We also believe in accountability, and holding the payers accountable is integral in the delivery of quality healthcare.
An AppriseMD client who sends overflow cases to AppriseMD for second-level and peer-to-peer reviews recently referred a case for a severity discussion with the payer’s medical director. The payer approved the IP admission but concluded that the case would only be reimbursed at the LLS rate. The AppriseMD physician advisor was able to reverse the LLS determination after engaging in a severity discussion with the payer medical director, and a high-severity payment was approved.
CLINICAL SUMMARY
A 67-year-old female with a history of morbid obesity (BMI 53), hypertension, chronic diastolic heart failure, CKD stage IV, atrial fibrillation, and prior pulmonary embolism on warfarin, presented to the ED with a sudden onset of severe shortness of breath, accompanied by chest pressure and dizziness. The patient’s medical history also included Crohn’s disease status post total colectomy with ileostomy. On admission, she was hypertensive up to 170/76, alert and oriented ×3, in no acute distress, but ill-appearing. Physical examination showed decreased breath sounds with rales on both lower lung fields and bilateral lower extremity edema. No evidence of upper or lower GI bleed. Initial workup showed hemoglobin 7.5 (baseline 12), hematocrit 26.1, INR 2.5, troponin T 16 → 19 → 21 (ref <11 ng/L), NT-proBNP 1,884, and a negative fecal occult blood test. Chest X-ray demonstrated mild diffuse bilateral reticular opacities compatible with pulmonary edema. EKG showed a normal sinus rhythm without ischemic changes.
The patient required telemetry monitoring, daily assessment of hemoglobin and hematocrit levels, and ongoing evaluation for any signs of bleeding while continuing warfarin therapy. She received IV Lasix with symptomatic improvement. IV iron therapy was initiated, increasing hemoglobin to 8.4 by hospital day (HD) 2. Transthoracic echocardiogram showed an EF of 65–70%. On HD3, hemoglobin decreased to 7.7 with reported dizziness on exertion and further declined to 7.4 on HD4. She remained on daily IV iron. By HD5, the patient was asymptomatic with hemoglobin stabilized at 7.8. She was discharged with stable vital signs on oral iron supplementation, with consideration for outpatient, periodic IV iron infusions.
SEVERITY DISCUSSION OUTCOME
A severity discussion was completed with the MA plan after the payer authorized the IP stay, but only approved it to be paid at the LLS rate. An AppriseMD physician advisor facilitated the severity review for this 67-year-old female patient who presented with symptomatic anemia causing shortness of breath and chest pain/ pressure. BNP was elevated, and the patient had bilateral lower extremity edema. Chest X-ray revealed mild diffuse bilateral reticular opacities. The payer medical director was reminded that the patient was treated with IV iron and IV furosemide due to persistent anemia and shortness of breath. The AppriseMD physician advisor also discussed the patient’s complex medical history, the need for close monitoring, and the continued medical management over several days. The severity review concluded with the payer medical director agreeing that the high severity payment determination was warranted and approved.
ABOUT APPRISEMD
AppriseMD provides denial management and physician advisory solutions to help hospitals and health systems optimize the revenue cycle with data transparency and operational efficiency.