Utilization Review

With COVID-19 continuing and staff shortages, hospitals need every financial advantage they can find

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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Should hospitals pursue appeals of Medicare denials?

Hospital executives and case review managers should soon see the back-logged appeals process speed up for denied Medicare claims. That means hospitals now have one less reason not to pursue appeals of Medicare denials. According to attorney Knicole C. Emanual, writing for RACmonitor, The Centers for Medicare and Medicaid Services (CMS) has given The Office …

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Eliminating the CMS inpatient only list will continue to complicate hospital stays

For an update on this issue, please read: CMS reverses course in inpatient only list   The Centers for Medicare & Medicaid Services (CMS) has begun to dismantle its inpatient only list, which has directed the level of care for more than 1700 procedures for physicians and hospitals since 2000. CMS said the move gives physicians …

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Utilization Review: In-house or Outsource?

Utilization management programs are often in-house services provided by hospital staff. However, more and more hospitals are outsourcing utilization review management as the pressure mounts to contain costs, especially following the COVID-19 pandemic, and improve care. Hospitals benefit from outsourcing utilization review in several ways, as it can: Free up in-house physician advisors and chief …

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Documentation – A Key for Reduced Denials

There is one relatively easy way hospitals can reduce claims denials: better clinical documentation. Insurance companies require documentation, and it is often the leading factor in level of care and admission denials. The importance of providing complete documentation never goes away. Treating physicians and utilization review managers must ensure that every admission includes: All the …

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A quiet shift that could shake up hospital Utilization Review

There is a seismic shift happening in Utilization Review: As of Saturday, May 1, 2021, UnitedHealthcare, the country’s largest healthcare insurance provider, is changing guidelines to adjudicate the level of care cases for hospitals from Milliman Care Guidelines (MCG) to InterQual.1 AppriseMD will be working closely with our current hospital clients to ensure this is …

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Recouping revenue lost to COVID

Utilization Review Managment can help hospitals with COVID revenue loss

COVID-19 continues to have detrimental effects not only on health of people, but also on the economy and businesses in general. Included in these businesses are hospitals which have been expected to be fully supplied, staffed and ready to provide cutting edge care throughout the pandemic.  According to a new report released in February from …

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Outpatient Arthroplasty Surgery: A Position Paper from AppriseMD

The American Association of Hip and Knee Surgeons have stated that hip and knee replacements can be safely performed in the outpatient setting in some specific circumstances. However, the wording implies the procedure is most appropriate in an ideal patient when performed in a facility and by a surgical team specifically equipped for this type …

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CASE STUDY: Can Peer-to-Peer Reviews Overturn Short Hospital Stay Inpatient Denials?

Inpatient admissions less than two days in length which have been denied by a commercial carrier are appropriate for Peer-to-Peer Review, but not all hospitals and doctors have the time or the will to do these reviews. Once we have moved past the extreme situation of the COVID-19 pandemic, hospitals are going to look hard …

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