Utilization Review

patient in wheelchair

Case Study: Inpatient Denial Overturned for Elderly Patient with Significant Risk Factors

Inpatient denials for elderly patients on Medicare Advantage plans can appear hard to refute due to the criteria laid out by CMS and health plans. However, significant risk factors such as prior recent strokes and urinary tract infections, especially in older patients, are reason enough to attempt to reverse the initial denial. See one case […]

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Hospital hallway with wheelchairs for discharge

Case Study: Awaiting Discharge to Skilled Nursing Facility

Extended hospital stays where a patient is medically ready to discharge but awaiting admission into a Skilled Nursing Facility or Acute Inpatient Rehabilitation continues to be an issue and can lead to revenue loss. AppriseMD recently overturned an inpatient denial for an 11-day hospital stay that was extended awaiting discharge. CLINICAL SUMMARY: Awaiting discharge to

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CMS proposed rule change laptop with text

CMS Proposed Rule Changes for MA Patients

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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Payer Prior Authorization Continues to Create Roadblocks

Doctors surveyed by the American Medical Association said the payer prior authorization (PA) process creates delays in care, abandoned treatments, and impacts outcomes. The complexity and inconsistencies of payer PA processes continue to create roadblocks to care for both patient and providers, including hospitals. Although the American Medical Association, along with the American Hospital Association,

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New UHC Hospital Services Observation and Inpatient Policy Takes Effect Dec. 1, 2022

UnitedHealthcare’s Observation Utilization Review Guide is sunsetting and will be replaced by the new Hospital Services: Observation and Inpatient Policy1. The change takes effect Dec. 1, 2022, for commercial, community and exchange plans. The new policy explicitly mentions InterQual, stating “InterQual criteria are intended to be used in connection with the independent professional medical judgment

New UHC Hospital Services Observation and Inpatient Policy Takes Effect Dec. 1, 2022 Read More »

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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Determining observation stay guidelines

Which Guidelines Should Hospitals Follow for an Observation Stay?

Both national evidence-based guidelines and insurance company guidelines factor into level of care determination.   When it comes to determining a patient’s level of care for a short hospital stay, observation services are generally used for short-term monitoring, testing and evaluation to establish a treatment plan, and to give the treatment team time to see

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Justice Department files lawsuit against UHC to stop Change Healthcare acquisition

Justice Department Files Lawsuit Against UnitedHealth to Stop Change Healthcare Acquisition

The United States Department of Justice filed an antitrust lawsuit earlier this year aiming to stop UnitedHealth Group from acquiring Change Healthcare.1 Hospital CFOs and utilization review managers have much to watch in this case related to how it could not only impact competition in the markets but how it could impact the guidelines used

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ehr, emr, electronic medical record graphic

Good Documentation can Reduce Hospital Admission Denials

We all know in clinical medicine that documentation is everything. Hence the old saying “If it’s not documented, then it didn’t happen.” This is particularly true outside of the clinical realm in the insurance world. Level of care is based on the clinical condition of the patient, how they present and how that meshes with

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Doctor with mask and stethoscope. Hospitals need every financial advantage they can to recoup revenue from the pandemic.

With COVID-19, Hospitals Need Every Financial Advantage

As hospitals in some areas face a new and devastating round of COVID-19 surges, the financial impact on those hospitals is not yet known. This new spike in cases comes on the heels of more than 16-months of instability caused by the pandemic and just when hospitals were starting to make gains financially. According to

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