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Physician Advisors: Specialists For Your Utilization Management Team

Physicians specialize in medicine for various reasons, though primarily to improve patient outcomes by providing more focused care and reducing medical errors. This also allows physicians to see more patients in a period, making them more efficient at delivering quality care. The concept of specialization in healthcare is not new, however it is not always […]

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Hospitals should file a complaint when the Medicare Advantage (MA) plans do not follow the Two-Midnight rule

Hospitals Should File A Complaint When Medicare Advantage Plans Do Not Follow Two-Midnight Rule

Blog, CMS, Medicare Advantage / By AppriseMD

An American College of Physician Advisors’ (ACPA) recent report concurs with earlier data from AppriseMD that many Medicare Advantage Organizations (MAOs) are not complying with the guidelines that the Centers for Medicare and Medicaid Services established under rule 4201-F. In its News to Note from July 20241, the ACPA looked at whether all of the

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the impact of weekend utilization review

The Financial Impact of Weekend Utilization Review

Blog, Utilization Review / By AppriseMD

Missing adequate weekend assessments exposes up to 29% of hospital days to potential payment issues. Physicians consider many factors during the complex clinical judgement used in determining a hospital admission. Many hospitals operate with reduced staffing on the weekends, and this can have a significant impact on reimbursement when factoring that weekends encompass approximately 105

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Payers, Artificial Intelligence and Revenue Cycle

Blog / By AppriseMD

As the use of artificial intelligence (AI) in healthcare claims management widens, the importance of careful oversight is needed. Any use of automation for claim denials should be scrutinized by providers to ensure the denial is appropriate. A recent Healthleaders report asked a key question all revenue cycle managers must consider: What is the balance

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Medicare Advantage Organization Non-Compliance with The Two-Midnight Rule Findings

Blog, CMS, Medicare Advantage, Two-Midnight Rule / By AppriseMD

AppriseMD hospital utilization review data for the first two months of 2024 shows that Medicare Advantage Organizations (MAOs) are denying claims that would have been approved under Traditional Medicare. BACKGROUND MAOs must adhere to the same guidelines as Traditional Medicare as per the Center for Medicare and Medicaid Services’ (CMS) 2024 rule 4201-F. MAOs can

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Centers for Medicare and Medicaid Services Final Rule 4201-F timeline

The Impetus Behind the 2024 CMS Final Rule

Blog, CMS, Medicare Advantage, Two-Midnight Rule / By AppriseMD

Arising from concerns that the Medicare Advantage Organizations (MAOs) were delaying and denying services and reimbursement, the Centers for Medicare and Medicaid Services (CMS) implemented 4201-F at the beginning of 2024. This rule was initiated after the publication of a report in April 2022 by the Office of the Inspector General (OIG), a division of

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HHS OIG Report Shows Code Adjustments May Indicate Denials

Blog, Denial Management, Medicare / By estevesmooreb

In a report released March 2 by OIG, investigators found “that most 2019 MA (Medicare Advantage) encounter records contained at least one adjustment code and 55 million of these records contained codes that may indicate the denial of payments by MAOs Medicare Advantage Organizations).” The report’s key take away was that while most of the

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CMS proposed rule change laptop with text

CMS Proposed Rule Changes for MA Patients

Blog, CMS, Length of Stay, Medicare, Utilization Review / By estevesmooreb

CMS proposed rule impacts how hospitals determine LOS for MA patients The Centers for Medicare and Medicaid Services (CMS) recently proposed rule changes (CMS-4201) that could have a significant impact on how hospital utilization management determines level of care for Medicare Advantage patients. The proposed rule1 reflects the agency’s focus on increasing transparency, improving health

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Which Guidelines Should Hospitals Follow for an Observation Stay?

Blog, Length of Stay, Utilization Review / By AppriseMD

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

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Justice Department files lawsuit against UHC to stop Change Healthcare acquisition

Justice Department Files Lawsuit Against UnitedHealth to Stop Change Healthcare Acquisition