Medicare

PA secondary reviews raise reimbursement

Case Study: Physician Advisor Secondary Review Insight on MA Case

Case Study, Denial Management, Medicare, Two-Midnight Rule / By

CLINICAL SUMMARY: An 88-year-old patient with a complex cardiac history of chronic congestive heart failure and dilated cardiomyopathy arrived at the emergency department (ED) with worsening shortness of breath and intermittent dizziness. The patient’s medical history included COPD, dilated cardiomyopathy, ventricular tachycardia with implantable cardioverter-defibrillator (ICD) shocks, atrial fibrillation (for which the patient uses Eliquis®), […]

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CMS IPO 2024

Case Study: IPO List Proves Critical in Overturning Denied Inpatient Stay

Case Study, Denial Management, Inpatient Only List, Medicare / By

CLINICAL SUMMARY: Doctors performed a scheduled hysteroscopy with dilation and curettage (D&C), endocervical myomectomy and MyoSure polypectomy on a 55-year-old patient who had been experiencing abnormal uterine bleeding with cervical fibroids and an endometrial polyp. The patient had a medical history which included pancreatitis due to alcoholism with a pseudocyst, deep venous thrombosis, hypertension, pleural

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Two-midnight rule helps overturn denial

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

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

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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Medical chart review

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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CMS proposed rule change laptop with text

CMS Proposed Rule Changes for MA Patients

Blog, CMS, Length of Stay, Medicare, Utilization Review / By

CMS proposed rule impacts how hospitals determine LOS for MA patients   The Centers for Medicare and Medicaid Services (CMS) recently proposed rule changes (CMS-4201) that could have a significant impact on how hospital utilization management determines level of care for Medicare Advantage patients. The proposed rule1 reflects the agency’s focus on increasing transparency, improving health

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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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AppriseMD physician advisors provide essential utilization review and denial management services to hospitals

How Does the Two-Midnight Rule Apply When a Traditional Medicare Patient Has No Safe Discharge Plan?

Blog, Length of Stay, Medicare / By

For a traditional Medicare patient admitted for observation, it is not uncommon to remain in the hospital longer than two midnights due to non-medical reasons including waiting for a transfer to another facility or family situations. In these cases, the reason the patient remains hospitalized is the lack of a safe discharge plan. Should such

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Doctors in surgery, CMS to keep inpatient only list

CMS to Keep the Inpatient Only List

Blog, Inpatient Only List, Length of Stay, Medicare / By

The Centers for Medicare and Medicaid Services’ decision to not eliminate the inpatient only list (IPO) was due to the numerous comments and feedback it received from the medical community, the COVID-19 public health emergency and the fact that the change “transpired quickly,” according to the final rule (CMS-1753FC) issued in December.1 Heading into 2022,

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Administrative law judge reviews appeals at the highest level

Appealing Denials through the Medicare Claims Appeals Process Works

Blog, Inpatient Only List, Length of Stay, Medicare / By

Though it took time and effort, an administrative law judge ruled in favor of a client hospital and overturned a Medicare claim denial for a total knee replacement surgery. The hospital can now fully recover the cost of that surgery, with interest. The case dates back to 2015 when a traditional Medicare patient underwent a

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