Denial Management

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Case Study: Two-Midnight Rule Helps Overturn Medicare Advantage Plan Inpatient Denial

CLINICAL SUMMARY: Two-Midnight Rule Helps Overturn Medicare Advantage Plan Inpatient Denial   A 68-year-old patient with an extensive medical history arrived at the emergency room after three days of acute gastrointestinal (GI) bleeding. The patient experienced nausea and observed bright red stool blood that persisted. The patient’s medical history included atrial fibrillation treated with an […]

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Doctor visits patient post-surgery in the hospital.

Case Study: Post-Surgery Inpatient Admission Denial Overturned

CLINICAL SUMMARY: Post-Surgery Inpatient Admission Deemed Medically Unnecessary Overturned A 52-year-old patient underwent a planned ventral incisional hernia operation, performed laparoscopically using an intraperitoneal onlay mesh placement. The patient was classified as ASA Class III, defined by the American Society for Anesthesiologists (ASA) for patients with “severe systemic disease that is not incapacitating” with a

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Physician advisors with hospital-based clinical experience combined with utilization management experience, can bring when it comes to reversing short stay denials.

Case Study: Medical Necessity Behind Short Stay is Key

CLINICAL SUMMARY: Medical Necessity Behind Short Stay is Key This case involves a one-day inpatient denial for a 30-year-old patient treated for acute pancreatitis. With abdominal pain and nausea, the patient went to the Emergency Department where he was found to have upper abdominal pain and tenderness, a lipase of 1,447 U/L (reference range 16-77

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Physicians in operating room

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

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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Diabetic patient testing blood

Case Study: Poorly Controlled Diabetes Inpatient Denial Overturned

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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Medical chart review

HHS OIG Report Shows Code Adjustments May Indicate Denials

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

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

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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