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Physician advisor reviews a lower level of severity determination after engaging in a severity discussion.

Case Study: High Severity Reimbursement Approved Following Severity Discussion

Case Study, Level of Care / By AppriseMD

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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For hospitals, high-level severity denials are a major challenge resulting in increased administrative, clinical and financial burdens.

Case Study: Underpayment Determination Reversed Following Severity Discussion

Case Study, Level of Care, Two-Midnight Rule / By AppriseMD

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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Case study reviews level of care severity

Case Study: Inpatient Level of Care Payment Review Reversed After Peer-to-Peer

Case Study, Level of Care, Peer-to-Peer / By AppriseMD

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

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Formal written appeals of an upheld peer-to-peer

Case Study: Formal Appeal Overturns Upheld Peer-to-Peer

Case Study, Denial Management, Formal Appeal, Peer-to-Peer / By AppriseMD

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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Case Study: Challenging MA Denial Overturned Despite One-Midnight Stay

Case Study, Two-Midnight Rule / By AppriseMD

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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infant failure to thrive in pediatric unit

Case Study: Infant Failure to Thrive Inpatient Denial Overturned

Case Study, Medicaid, Peer-to-Peer / By AppriseMD

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

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Case Study Readmission Unlinked after P2P

Case Study: Unlinking a Readmission Hospitalization During a Peer-to-Peer Payer Review

Case Study, Peer-to-Peer, Readmission / By AppriseMD

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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Case Study: Secondary Review Recommendation Holds in Cellulitis Hospitalization

Case Study, Denial Management, Second-Level Review / By AppriseMD

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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Doctors work on a patient in the Emergency Department

Case Study: New DRG Key to Overturning MCO Denial

Case Study, Denial Management, Peer-to-Peer / By AppriseMD

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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Doctor performs labs in emergency department.

Case Study: Readmission Linking Denial Overturned After P2P