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,
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 »
We all know in clinical medicine that documentation is everything. Hence the old saying “If it’s not documented, then it didn’t happen.” This is particularly true outside of the clinical realm in the insurance world. Level of care is based on the clinical condition of the patient, how they present and how that meshes with
Good Documentation can Reduce Hospital Admission Denials Read More »
As hospitals in some areas face a new and devastating round of COVID-19 surges, the financial impact on those hospitals is not yet known. This new spike in cases comes on the heels of more than 16-months of instability caused by the pandemic and just when hospitals were starting to make gains financially. According to
With COVID-19, Hospitals Need Every Financial Advantage Read More »
After what must have been significant feedback, the Centers for Medicare & Medicaid Services is now reversing its move to eliminate the inpatient only (IPO) list in 2022 and add back the 298 services removed from the IPO list in 2021. 1 If this goes through in 2022, it will require hospitals to be extra
For an update on this issue, please read: CMS reverses course in inpatient only list The Centers for Medicare & Medicaid Services (CMS) has begun to dismantle its inpatient only list, which has directed the level of care for more than 1700 procedures for physicians and hospitals since 2000. CMS said the move gives physicians
Eliminating the CMS IPO List will Continue to Complicate Hospital Stays Read More »
Utilization management programs are often in-house services provided by hospital staff. However, more and more hospitals are outsourcing utilization review management as the pressure mounts to contain costs, especially following the COVID-19 pandemic, and improve care. Hospitals benefit from outsourcing utilization review in several ways, as it can: Free up in-house physician advisors and chief
There is one relatively easy way hospitals can reduce claims denials: better clinical documentation. Insurance companies require documentation, and it is often the leading factor in level of care and admission denials. The importance of providing complete documentation never goes away. Treating physicians and utilization review managers must ensure that every admission includes: All the
There is a seismic shift happening in Utilization Review: As of Saturday, May 1, 2021, UnitedHealthcare, the country’s largest healthcare insurance provider, is changing guidelines to adjudicate the level of care cases for hospitals from Milliman Care Guidelines (MCG) to InterQual.1 AppriseMD will be working closely with our current hospital clients to ensure this is
A Quiet Shift that Could Shake Up Hospital Utilization Review Read More »