Peer-to-Peer

Formal written appeals of an upheld peer-to-peer

Case Study: Formal Appeal Overturns Upheld Peer-to-Peer

Case Study, Denial Management, Formal Appeal, Peer-to-Peer / By

THE CHALLENGE Hospitals continue to face payer denials throughout the revenue cycle, including technical and administrative denials, as well as coding denials where Diagnostic Related Group (DRG) downgrades are a major pain point. Clinical denials are also rampant, whereby the payers are challenging the clinical judgement of providers despite clear evidence that, for example, inpatient […]

Case Study: Formal Appeal Overturns Upheld Peer-to-Peer Read More »

Nurse checks on infant in hospital

Case Study: Infant Failure to Thrive Inpatient Denial Overturned

Case Study, Medicaid, Peer-to-Peer / By

CLINICAL SUMMARY: A newborn infant, just over one-month-old, arrived at the Emergency Department (ED) under the direction of a pediatrician, who was concerned about lack of weight gain since birth. The infant was born weighing 8 pounds, 5 ounces and weighed 8 pounds, 5.5 ounces one month and five days after birth. The patient’s weight

Case Study: Infant Failure to Thrive Inpatient Denial Overturned Read More »

Case Study Readmission Unlinked after P2P

Case Study: Unlinking a Readmission Hospitalization During a Peer-to-Peer Payer Review

Case Study, Peer-to-Peer, Readmission / By

CLINICAL SUMMARY: A 70-year-old patient arrived in the Emergency Department (ED) from an assisted living facility (ALF) as his renal function deteriorated, and he slipped into a severely depressive state. The patient appeared pale and withdrawn, and the ALF staff reported that the patient did not eat or drink for approximately three weeks. Additionally, the

Case Study: Unlinking a Readmission Hospitalization During a Peer-to-Peer Payer Review Read More »

Doctors work on a patient in the Emergency Department

Case Study: New DRG Key to Overturning MCO Denial

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

CLINICAL SUMMARY: A 34-year-old patient arrived in the emergency department (ED) experiencing complications from alcohol withdrawal, which began while staying at a sober living home. He began experiencing lightheadedness, nausea, vomiting and epigastric pain in addition to developing a bilateral rash to his upper extremities and was transported to the ED. The patient reported drinking

Case Study: New DRG Key to Overturning MCO Denial Read More »

Doctor performs labs in emergency department.

Case Study: Readmission Linking Denial Overturned After P2P

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

CLINICAL SUMMARY: A 79-year-old male patient arrived in the emergency department (ED) complaining of weakness, extreme lethargy and the inability to eat for the past three days. The patient’s past medical history included prostate cancer s/p resection with metastases to the bladder and lumbar spine on antiandrogen, hypothyroidism, hypertension, hyperlipidemia, CAD s/p stent placement x2,

Case Study: Readmission Linking Denial Overturned After P2P Read More »

emergency-hospital-sign

Case Study: Profound Obesity Risk Factor Overturns Denied Inpatient Stay

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

CLINICAL SUMMARY: A 29-year-old male patient with no significant past medical history arrived at the Emergency Department with ongoing abdominal pain, cramping and tenderness in the left upper quadrant and epigastric region. This patient presented with a weight of 523 pounds, a BMI of 87 and labs as follows: WBC 12.07, ANC 9.34, Hgb 13.4,

Case Study: Profound Obesity Risk Factor Overturns Denied Inpatient Stay Read More »

patient with Lennox-Gastaut syndrome, a complex, rare and severe childhood-onset epilepsy

Case Study: Short Stay Involving a Patient with Lennox-Gastaut Syndrome Highlights the Need for P2P

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

CLINICAL SUMMARY: A six-year-old male patient with Lennox-Gastaut syndrome, a complex, rare and severe childhood-onset epilepsy, arrived in the emergency department (ED) after experiencing breakthrough cluster seizures at home and en route to the hospital after starting a new treatment medication the day prior. Once in the ED, the patient experienced three more seizures, one

Case Study: Short Stay Involving a Patient with Lennox-Gastaut Syndrome Highlights the Need for P2P Read More »

MA patient in hospital

Case Study: MA Denial Overturned

Case Study, Medicare Advantage, Peer-to-Peer, Two-Midnight Rule / By

AppriseMD recently argued that the presence of a rise in creatinine constituted hypertensive end-organ damage, which was the key factor for a Medicare Advantage denial being overturned. CLINICAL SUMMARY: An elderly patient with a history of hypertension and thyroid disease sought treatment in the emergency department after a fall. The patient suffered a closed head

Case Study: MA Denial Overturned Read More »

AppriseMD Case Study: Complex Medical History, ICD & Transfer Impact Inpatient Denial Reversal

Case Study: Complex Medical History, ICD & Transfer Impacts Inpatient Denial

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

An inpatient level of care (LOC), initially denied by a Medicare Advantage payer, was approved after a peer-to-peer discussion involving a stable patient with a complex medical history and condition that required a transfer to a higher LOC. The short stay exemplifies the importance of having physicians with both payer and clinical experience facilitate the

Case Study: Complex Medical History, ICD & Transfer Impacts Inpatient Denial Read More »

Blood work for DKA testing

Case Study: Short Stay Common Diabetic Ketoacidosis Denial Overturned

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

Can hospitals receive full inpatient admission reimbursement for a patient experiencing diabetic ketoacidosis who only spends one night in the hospital? AppriseMD’s latest case study shows that it is possible. A young adult patient with type 1 diabetes struggling with consistent vomiting over two weeks stayed one night as a hospital inpatient, but commercial insurance

Case Study: Short Stay Common Diabetic Ketoacidosis Denial Overturned Read More »

Scroll to Top