CASE STUDY:

Overturning Inpatient-Stay Denials

Difficult inpatient-stay denials

CLINICAL SUMMARY

A 66 year-old patient undergoing total hip arthroplasty. The patient received an ASA score of 3, having multiple comorbidities including asthma and need for postoperative supplemental oxygen therapy.

operation, operating room, doctor

INITAL PATIENT CLASS

A scheduled arthroplasty was denied by a commercially managed Medicare insurance company based on the evidence that the patient’s signs and/or symptoms were not severe enough to need services that could only be provided safely and effectively on an inpatient basis. The recommendation was this patient’s total hip arthroplasty could have been safely done in an outpatient setting

APPRISEMD RECOMMENDED CLASS

Our physician reviewer argued that given this patient’s ASA score of 3, multiple comorbidities including asthma and need for postoperative supplemental oxygen therapy warranted inpatient level of care for his total hip arthroplasty. Despite moves to outpatient status, AppriseMD believes that most total hip arthroplasties should be inpatient.

Read more about this position.

OUTCOME: DENIAL OVERTURNED

The denial was overturned by the insurance company. The patient righteously was covered for the inpatient medical and supportive care he needed and the hospital was covered for the resources utilized to provide the utmost care for this patient.

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Can Peer-to-Peer reviews overturn short hospital stay in-patient denials? We have done a limited study and seen the benefit of P2P reviews at AppriseMD and how it can reverse denials and recoup dollars for hospitals.

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