Case Study

Hospital hallway with wheelchairs for discharge

Case Study: Awaiting Discharge to Skilled Nursing Facility

Case Study, Discharge, Utilization Review / By

Extended hospital stays where a patient is medically ready to discharge but awaiting admission into a Skilled Nursing Facility or Acute Inpatient Rehabilitation continues to be an issue and can lead to revenue loss. AppriseMD recently overturned an inpatient denial for an 11-day hospital stay that was extended awaiting discharge. CLINICAL SUMMARY: Awaiting discharge to […]

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Diabetic patient testing blood

Case Study: Poorly Controlled Diabetes Inpatient Denial Overturned

Case Study, Denial Management / By

Hospital utilization management requires constant communication between the utilization management team and physician advisors as well as continuously reassessing observation cases for possible conversion to inpatient status. Missing these opportunities leads to increased observation rates and reduced revenue. It can also lead to patients potentially requiring ongoing medical care beyond the observation period. Such patients

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Patient with total knee replacement

Case Study: Total Knee Replacement Inpatient Denial Overturned

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Inpatient stays for procedures commonly done on an outpatient basis can lead to denials. But appealing the denials does have promise. A recent denial for a total knee replacement that was overturned due to the patient’s high risk factors and complex medical history. CLINICAL SUMMARY: Total Knee Replacement A 67-year-old patient underwent a left total

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patient sitting alone in hospital room

Case Study: Type 2 Diabetes and Chronic Kidney Disease

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Even with concerns about days spent waiting on a transfer to a higher level of care, an insurance company medical director reversed an inpatient stay denial after a Peer-to-Peer discussion of the case. CLINICAL SUMMARY: Type 2 Diabetes and Chronic Kidney Disease A 40-year-old patient arrived in the Emergency Department complaining of worsening right upper

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Case study hyperemesis gravidarum 4-day inpatient stay

Case Study: Hyperemesis Gravidarum 4-day Inpatient Stay

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After overturning a four-day inpatient denial for a 13-week pregnant patient with hyperemesis gravidarum and severe pain, the insurance company medical director commented that it is very difficult to overturn these cases. Just another example of the importance of detailed follow-up Peer-to-Peer discussions, even in denied cases that seem “hopeless” to be overturned. CLINICAL SUMMARY:

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Medical chart documentation

Case Study: Hospital Stay Due to Injury and Complex Medical History

Case Study / By

According to the CDC’s National Center for Health Statistics*, there are 130 million visits a year to Emergency Departments, 35 million of which are injury related. Many injury-related ER visits do not result in admission to the hospital, but for those that do, hospital utilization review managers need to provide insurance companies sufficient documentation showing

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Case study alcohol withdrawal and AMA departure can still qualify as inpatient stay

Case Study: Alcohol Withdrawal and AMA Departure Can Still Qualify as Inpatient Stay

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Does leaving the hospital against medical advice (AMA) equal an outpatient short stay? Not necessarily. AppriseMD reviewed one inpatient denial case involving a patient who left the hospital AMA after a two-day stay due to severe alcohol withdrawal and seizures. The AppriseMD physician reviewer was able to overturn the denial after a discussion with the

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