A Collection of Case Studies, Position Papers and White Papers from AppriseMD
Beyond the Pandemic Part 2
As the pandemic recedes, the average length of stay continues to increase nationwide despite a drop in COVID-related illnesses. The American Hospital Association* reported that the average patient length of stay increased by 19.2% in 2022 compared to pre-pandemic levels. A combination of factors was responsible for this change. This included sicker patients presenting to the hospitals because of delayed care, the resulting bottlenecks in the emergency room, the backlog of elective procedures hitting the system, and hospital admission spikes from new COVID variants, RSV infections and seasonal flu outbreaks. Barriers to patient flow were added by the increasing complexity of patient discharge planning and changing patterns of post-acute care. On top of this, staffing issues placed burdens on hospitals exacerbating difficulties. It is clear hospitals will continue to face challenges in 2023. Understanding the residual effects caused by the pandemic, their root causes, and their impact on the continuum of care, is critical to building strategies to effectively manage hospital capacity and resources.
In Part 2 of our compendium of research, we look at strategies to bend hospital utilization curves by right sizing length of stay as well as keys to addressing post-disc.
Click here to download our in-depth look at post pandemic hospital trends.
Beyond the Pandemic Part 1
In 2020, hospitals encountered a crisis unlike any they had faced before. More than two years later, hospitals are still coping with the repercussions of the COVID-19 pandemic both in terms of patient volumes and financial challenges.
In 2021 and 2022, as COVID-related illnesses waned, the average length of stay (ALOS) and patient acuity continued to increase across the U.S. as hospitals began to see sicker patients due to an extended period of delayed care. This new trend emerged as pent-up demand for elective procedures increased and spikes in hospitalizations continued to cycle in the fall of 2022 due to things like new COVID variants and a respiratory syncytial virus (RSV) outbreak. Understanding the changes caused by the pandemic, their root causes and their impact on hospitals is critical in building strategies that will help hospitals address the trends.
Hospitals, treating physicians and utilization review managers will need to intensify the use of past tools and adjust approaches to meet the patterns that have developed post pandemic due to the pent-up needs and delayed care. Strategies to bend hospital utilization curves will require that all departments coordinate care from the emergency department and inpatient units to discharge planning and utilization review management teams to skilled nursing facilities, and, finally, to home care.
Click here to download our in-depth look at post pandemic hospital trends.
Dealing with Denials
Ultimately hospitals and other healthcare providers can no longer ignore the impact inpatient denials can have on their cash flow. Ninety percent of all denials are preventable, so why aren’t more denials being prevented? If an organization takes a focused and unremitting approach to tackling this problem, it can see improvements in lowering denials and increasing overturned denials. This approach requires persistence and commitment to proper documentation, plus a clear utilization review strategy together with a team approach. The result will help support the financial health and future
sustainability of the organization.
Read more of our in-depth look at the causes of inpatient denials - and what healthcare organizations can do to keep them from happening.
Rightsizing Length of Stay
Hospitals working to improve efficiency by rightsizing length of stay and reducing avoidable hospital inpatient days must implement a process that begins prior to admission and extends beyond discharge. Extended hospital stays beyond what is needed for high quality care and avoidable readmissions, can be associated with an increased potential for complications such as hospital acquired infections and patient safety events. Reducing extended stays relies on a coordinated, multi-facetted process to reach the desired outcomes.
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 of Medicare Hearings and Appeals (OMHA) enough new funding to hire 70 additional administrative law judges. These new judges will be charged with hearing the backlog of appeals cases that up until now had a 4-6-year waiting period. Emanual writes, “OMHA now has the capacity to hear and render decisions for approximately 300,000 appeals per year,” which she said was higher than the number of appeals being filed.1
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 of procedure. The clear implication is that an outpatient procedure should not be a viewed as an appropriate or mandatory setting for arthroplasty procedures.
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 at finding any way they can recoup dollars. We have done a limited study and seen the benefit of P2P reviews at AppriseMD and how it can reverse denials and recoup dollars for hospitals.
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 […]Read More
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 […]Read More
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 […]Read More
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 […]Read More