THE CHALLENGE LA recent report identified prior authorization request denials by Medicare Advantage Organizations (MAOs) for post-acute care to be a particular area of concern. The report, published by the Department of Health and Human Services Office of Inspector General (HHS-OIG), raised concerns that the MAOs may be inappropriately denying care, evidenced by the 95% […]
THE CHALLENGE Last year, several payers implemented or announced some tactical changes in their provider reimbursement policies. The providers took a hit with these evaluation and management (E/M) downcoding programs, resulting in lower-tier payments to providers if the payers disagreed with the severity of the patients’ illnesses. Regulatory review has sidelined the rollout of some
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THE CHALLENGE For hospitals, high-level severity denials are a major challenge resulting in increased administrative, clinical and financial burdens. One major concern is the dodging of the Two-Midnight rule, which was finalized under CMS-4201-F in April of 2023. The Two-Midnight rule sets the precedent that patients are appropriate for inpatient admission if the admitting physician
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THE CHALLENGE Many hospitals and health systems have been forced to navigate a new payer tactic that does not result in a formal denial of inpatient (IP) level of care (LOC). Instead, the payer affirms that IP admission was medically necessary, but reimbursement is reduced due to a perceived lack of severity for the billed
Case Study: Inpatient Level of Care Payment Review Reversed After Peer-to-Peer Read More »
THE CHALLENGE Hospitals continue to face payer denials throughout the revenue cycle, including technical and administrative denials, as well as coding denials where Diagnostic Related Group (DRG) downgrades are a major pain point. Clinical denials are also rampant, whereby the payers are challenging the clinical judgement of providers despite clear evidence that, for example, inpatient
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CLINICAL SUMMARY: A 76-year-old female arrived at the emergency department critically ill, experiencing palpitations and shortness of breath. The patient had a complex medical history including ovarian and thyroid cancers, chronic heart failure (CHF) with reduced ejection fraction (EF 20%), stage 3b chronic kidney disease, gastroesophageal reflux disease, paroxysmal atrial fibrillation (A-fib) on anticoagulation, type 2
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CLINICAL SUMMARY: A newborn infant, just over one-month-old, arrived at the Emergency Department (ED) under the direction of a pediatrician, who was concerned about lack of weight gain since birth. The infant was born weighing 8 pounds, 5 ounces and weighed 8 pounds, 5.5 ounces one month and five days after birth. The patient’s weight
Case Study: Infant Failure to Thrive Inpatient Denial Overturned Read More »
CLINICAL SUMMARY: A 70-year-old patient arrived in the Emergency Department (ED) from an assisted living facility (ALF) as his renal function deteriorated, and he slipped into a severely depressive state. The patient appeared pale and withdrawn, and the ALF staff reported that the patient did not eat or drink for approximately three weeks. Additionally, the
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CLINICAL SUMMARY: A 35-year-old patient arrived in the Emergency Department suffering from a painful abscess and swelling on the left buttock. The patient, whose medical history includes hidradenitis suppurativa, bipolar 1 disorder and asthma, described the pain as an excruciating stabbing sensation rated at a level 10. Furthermore, the patient reported shortness out of breath
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CLINICAL SUMMARY: A 34-year-old patient arrived in the emergency department (ED) experiencing complications from alcohol withdrawal, which began while staying at a sober living home. He began experiencing lightheadedness, nausea, vomiting and epigastric pain in addition to developing a bilateral rash to his upper extremities and was transported to the ED. The patient reported drinking
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