The Centers for Medicare & Medicaid Services (CMS) began dismantling the Inpatient Only (IPO) list on January 1, 2026, by removing 285 musculoskeletal, orthopedic and spine procedures. This phasing out process will happen over the next three years1, allowing more procedures to be performed on an outpatient basis, which CMS believes will result in a […]
Hospitals and health systems across the country are preparing for a significant shift in how Aetna reimburses certain inpatient stays. Aetna’s Level of Severity Inpatient Payment Policy, which went into effect January 1, 2026, (updated from the original effective date of November 15, 2025) introduced a new framework for evaluating and reimbursing urgent or emerging
Understanding Aetna’s New Level of Severity Inpatient Payment Policy Read More »
Exploring effective denial management strategies makes a significant difference for a hospital’s bottom line. One key component that hospitals and health systems should no longer be overlooking is specialized physician advisors who can transform revenue cycles and ensure higher quality care while safeguarding revenue streams. The latest and best solutions for improving revenue cycle and
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
Physician Advisors: Specialists For Your Utilization Management Team Read More »
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
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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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
Payers, Artificial Intelligence and Revenue Cycle Read More »
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
Medicare Advantage Organization Non-Compliance with The Two-Midnight Rule Findings Read More »
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
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
HHS OIG Report Shows Code Adjustments May Indicate Denials Read More »