Denial Management

Patient undergoes surgery in hospital.

Case Study: TKA Inpatient Status Denied Despite Being on CMS Inpatient Only List

Case Study, Denial Management, Inpatient Only List / By

Insurance companies are more likely to approve inpatient status for surgeries included on the CMS Inpatient Only List (IPO). Total knee replacements and total hip replacements are two common procedures on the IPO list. A Peer-to-Peer review can help reverse a denial for a inpatient stay for these types of cases. CLINICAL SUMMARY: TKA Inpatient …

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Poorly controlled diabetes inpatient denial case study

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, reduced revenue, and potential Patients requiring ongoing medical care beyond the observation period should be constantly reassessed for inpatient status …

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Physician advisors and case preparation physicians work with hospital UR teams to optimize reimbursement

HHS OIG Report Shows Code Adjustments May Indicate Denials

Blog, Denial Management, Medicare / By

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 …

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without proper documentation inpatient denials are often upheld

Without Proper Documentation, Inpatient Denials are Often Upheld

Denial Management, Utilization Review / By

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 …

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Medicare Appeals Process Needs Changes

Medicare Appeals Process Needs to be Amended

Appeal Management, Denial Management, Medicare / By

In her recent article, “Ghosting the Medicare Provider Appeals Process,” Knicole C. Emanuel Esq. argues that the process by which denied Medicare claims are reviewed and appealed is counter to rest of the U.S. legal system. The lengthy process for addressing denied Medicare claims is multi-tiered and, until recently, hampered by a years-long backlog due …

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