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 how code adjustments may indicate denials by MAOs Read More »
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 …
UnitedHealthcare’s Observation Utilization Review Guide is sunsetting and will be replaced by the new Hospital Services: Observation and Inpatient Policy1. The change takes effect Dec. 1, 2022, for commercial, community and exchange plans. The new policy explicitly mentions InterQual, stating “InterQual criteria are intended to be used in connection with the independent professional medical judgment …
New UHC Hospital Services Observation and Inpatient Policy takes effect Dec. 1, 2022 Read More »
Peer-to-peer discussions between hospital physicians – or their physician advisors – and the insurance company’s medical director can often overturn inpatient denials. But without proper documentation they do not work to rescind denials. Proper documentation must include an assessment coinciding with a detailed treatment plan updated throughout hospitalization. AppriseMD recently recommended to appeal a case …
Without proper documentation, inpatient denials are often upheld Read More »
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 …
Which guidelines should hospitals follow for an observation stay? Read More »
The United States Department of Justice filed an antitrust lawsuit earlier this year aiming to stop UnitedHealth Group from acquiring Change Healthcare.1 Hospital CFOs and utilization review managers have much to watch in this case related to how it could not only impact competition in the markets but how it could impact the guidelines used …
The American Hospital Association (AHA) updated rural hospital leaders regarding its 2022 Rural Advocacy Agenda during the recent AHA Rural Health Care Leadership Conference in Phoenix, AZ, attended by AppriseMD CEO Franklin E Baumann, MD. “The 2022 Rural Advocacy Agenda focuses on broader, forward-looking legislative and regulatory priorities that are not necessarily connected to the …
AHA’s advocacy of rural hospital issues is needed Read More »
For a traditional Medicare patient admitted for observation, it is not uncommon to remain in the hospital longer than two midnights due to non-medical reasons including waiting for a transfer to another facility or family situations. In these cases, the reason the patient remains hospitalized is the lack of a safe discharge plan. Should such …
The Centers for Medicare and Medicaid Services’ decision to not eliminate the inpatient only list (IPO) was due to the numerous comments and feedback it received from the medical community, the COVID-19 public health emergency and the fact that the change “transpired quickly,” according to the final rule (CMS-1753FC) issued in December.1 Heading into 2022, …
Several factors and considerable feedback led CMS to keep the inpatient only list Read More »
Though it took time and effort, an administrative law judge ruled in favor of a client hospital and overturned a Medicare claim denial for a total knee replacement surgery. The hospital can now fully recover the cost of that surgery, with interest. The case dates back to 2015 when a traditional Medicare patient underwent a …
Appealing denials through the Medicare Claims Appeals Process works Read More »