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Healthcare Information Research

A Collection of Case Studies, Position Papers and White Papers from AppriseMD

Rightsizing Length of Stay

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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.

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Should hospitals pursue appeals of Medicare denials?

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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

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Outpatient Arthroplasty Surgery: A Position Paper from AppriseMD

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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.

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

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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.

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AppriseMD Blog

How does the two-midnight rule apply when a traditional Medicare patient has no safe discharge plan?

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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Several factors and considerable feedback led CMS to keep the inpatient only list

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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Appealing denials through the Medicare Claims Appeals Process works

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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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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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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