Level of Care

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

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

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

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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